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RADIO-DIAGNOSIS  OF 
PLEURO-PULMONARY  AFFECTIONS 


PUBLISHED  UNDER  THE  AUSPICES  OF  THE 

YALE  SCHOOL  OF  MEDICINE 

ON  THE  FOUNDATION  ESTABLISHED  IN  MEMORY  OF 

WILLIAM  CHAUNCEY  WILLIAMS,  M.D., 

OF  THE  CLASS  OF  1822,  YALE  MEDICAL  SCHOOL 
AND  OF 

WILLIAM  COOK  WILLIAMS,  M.D., 

OF  THE  CLASS  OF  1850,  YALE  MEDICAL  SCHOOL. 


RADIO-DIAGNOSIS 

OF 

PLEURO-PULMONARY  AFFECTIONS 


BY 

F.  BARJON 

TRANSLATED  BY 

JAMES  A.  HONEIJ,  M.D. 

ASSISTANT  PROFESSOR  OF  MEDICINE 

IN  CHARGE  OF  RADIOGRAPHY 

YALE  MEDICAL  SCHOOL 


NEW  HAVEN 

YALE  UNIVERSITY  PRESS 

LONDON:  HUMPHREY  MILFORD 

OXFORD  UNIVERSITY  PRESS 

MDCCCCXVIII 


KC7^'/ 


c.z, 


COPYRIGHT,  1918,  BY 
YALE  UNIVERSITY  PRESS 


First  published  May,  1918. 


CO 

en 


THE  WILLIAMS  MEMORIAL  PUBLICATION  FUND 

THE  present  volume  is  the  second  work  published  by  the 
Yale  University  Press  on  the  Williams  Memorial  Publi- 
cation Fund.  This  Foundation  was  established  June  15th, 
1916,  by  a  gift  made  to  Yale  University  by  George  C.  F. 
Williams,  M.D.,  of  Hartford,  a  member  of  the  Class  of 
1878,  Yale  School  of  Medicine,  where  three  generations  of  his 
family  studied — his  father,  William  Cook  Williams,  M.D., 
in  the  Class  of  1850,  and  his  grandfather,  William  Chauncey 
Williams,  M.D.,  in  the  Class  of  1822. 


CONTENTS 

INTRODUCTION 

Page 
General  considerations  on  the  use  of  radiological  examination 

of  the  thorax  in  clinical  medicine xv 

Favorable  conditions  for  examination  of  the  thorax xv 

Importance  of  examination  of  the  thorax xvi 

■  Necessity  of  combined  medical  examination xvii 

PART  I:  METHODS  OF  EXAMINATION 

Chapter  I.  Radioscopic  Examination  of  the  Thorax.  ...  1 

Normal  images 1 

Frontal  position 1 

Dorsal  position 4 

Transverse  position 4 

Oblique  position 5 

Procedure 6 

Complete  examination 6 

Detailed  examination 6 

Examination  of  the  apices,  hilus,  interlobes,  sinuses. .  .  7 

Examination  of  the  diaphragm,  lungs,  ribs 8 

Abnormal  images 8 

Conclusion 10 

PART  II:  RADIOLOGICAL  STUDY  OF  THE  PLEURA 

Chapter  I.  Pleurisy  of  the  Large  Cavity 15 

Pleurisy  with  effusion 15 

General  appearance  of  the  thorax 15 

Upper  limit  of  the  effusion 16 

Curve  of  Damoiseau 18 

Study  of  the  diaphragm 20 

Displacement  of  heart  and  mediastinum 22 

Development  and  retrogression 23 

Radiological  diagnosis 24 


X  CONTENTS 

Page 

Pseudo-effusions 24 

Large  total  effusion 26 

Association  of  pulnionarj'-  lesions 26 

Slight  effusion  or  effusions  in  retrogression 28 

Difficulty  of  diagnosis  in  children 28 

Diagnosis  of  type  of  pleurisy 28 

Radiological  prognosis  of  pleurisy :  its  after  effects 29 

Dry  pleuris}^ 31 

Partial  dry  pleurisy 31 

Total  or  verj^  extensive  dry  pleurisy 31 

Chapter  II.  Circumscribed  and  Encysted  Pleurisy  ....  34 

Interlobar  pleurisy 34 

Interlobar  pleuris}-  with  effusion 35 

False  recovery  through  vomica 37 

Sclerosis  of  the  interlobe 39 

Diaphragmatic  pleurisy 40 

Purulent  diaphragmatic  pleurisy 40 

Serous  diaphragmatic  pleurisy 42 

Dry  diaphragmatic  pleurisy,  adhesions 44 

Mediastinal  pleuris}^ 45 

Mediastinal  pleurisy  with  effusion 46 

Dry  mediastinal  pleurisy 49 

Pleurisy  of  the  hilus  region.    Hilus  open  space  of  the  pleura  49 

Chapter  III.  Pneumothorax 56 

Spontaneous  pneumothorax 58 

Movement  of  balance 60 

Theory  of  paralysis  of  diaphragm 61 

Theory  of  thoracic  aspiration 61 

Theory  of  flattening  of  diaphragm 62 

Limited  or  encysted  pneumothorax 70 

Double  pneumothorax 72 

Artificial  pneumothorax 72 

Radioscopic  examination  during  treatment 75 

PART  III:  RADIOLOGICAL  STUDY  OF  THE  BRONCHI 

Chapter  1.  Foreign  Bodies  in  the  Bronchi 81 

Nature  of  foreign  bodies 81 


CONTENTS  xi 

Page 

Location  of  foreign  bodies 82 

Visibility.     Mobility 82 

Tolerance  and  infection 83 

Diagnosis 84 

Chapter  II.  Bronchial  Affections 85 

Acute  bronchitis 85 

Chronic  bronchitis 85 

Bronchial  stenosis.    Dilatation  of  the  bronchi 86 

Chapter  III.  Tracheo-Bronchial  Adenopathy 89 

Distinction  between  different  groups  of  glands 89 

Morphological  significance 90 

Radioscopic  image.    Diagnosis 91 

PART  IV:  RADIOLOGICAL  STUDY  OF  THE  LUNGS 

Chapter  I.  Vascular  Processes 99 

Congestions 99 

(Edemas 100 

Infarct 101 

Chapter  II.  Acute  Infectious  Pulmonary  Processes  ....  102 

Pneumonia 102 

Pneumonia  in  children 102 

Pneumonia  in  adults 103 

Value  of  pneumonic  triangle 105 

Broncho-pneumonia 106 

Pseudo-lobar  form 106 

Lobular  form 107 

Abscess  of  the  lung 108 

Pulmonary  gangrene Ill 

Chapter  III.  Chronic  Pulmonary  Processes 113 

Pulmonary  emphysema 113 

Pulmonary  sclerosis 114 

Atelectasis 115 

Chapter  IV.  Pulmonary  Tuberculosis 117 

Pulmonary  tuberculosis  without  clinical  or  stethoscopic  signs  118 


xii  CONTENTS 

Page 

Pulmonary  tuberculosis  with  clinical  signs  but  stethoscopic 

signs  negative,  doubtful  or  very  limited 120 

Examination  of  apices 120 

Examination  of  hilus 123 

Examination  of  interlobes 124 

Examination  of  thoracic  cavity  and  heart 125 

Study  of  respiration 125 

Pulmonary  tuberculosis  with  definite  clinical  and  stetho- 
scopic signs 127 

Radioscopic  appearance  of  thorax 128 

Pseudo-tuberculosis 129 

Topographic  study  of  lesions 132 

Stud}^  of  development  of  lesions 134 

Pulmonary-  cavities 135 

Study  of  complications 136 

Radioscopic  examination  and  treatment 140 

Cured  tuberculous  cases 140 

Chapter  V.  Lung  Tumors 142 

Cancer  of  the  lung 142 

Primary  cancer 143 

Secondary  cancer 144 

Cancer  of  the  pleura 148 

Hydatid  cysts  of  lung  and  dennoid  cysts  of  thorax 148 

Differential  diagnosis  of  cyst 149 

Localization 150 

Diagnosis  of  nature  of  cyst 152 

Hydatid  cysts  emptied  by  vomica 152 

PART  V:  PENETRATING  WOUNDS  OF  THE  THORAX  BY 

WAR  PROJECTILES 

Chapter  I.  Clinical  Study 157 

Symptoms  and  diagnosis 157 

Form,  development,  complications,  prognosis 159 

Radiological  study 161 

Nature  of  projectiles 161 

Search  for  projectiles 162 

Position  of  projectiles 162 


CONTENTS  xiii 

Page 

Localization 163 

Calculation  of  depth 164 

Surgical  application 165 

Difficulty  of  applying  these  methods  in  pulmonary  cases  166 

Function  of  radiologist 168 

Course  of  procedure.     Indications  and  contra-indications 

for  operation 170 

Positive  and  urgent  indication 171 

Positive  indication,  not  urgent 171 

Debatable  indications 172 

Contra-indications 173 

Note 174 


INTRODUCTION 

GENERAL  CONSIDERATIONS  ON  THE  USE  OF  RADIO- 
LOGICAL EXAMINATION  OF  THE  THORAX  IN  CLIN- 
ICAL MEDICINE 

THE  progress  made  during  the  last  few  years  in  the 
technique  of  radiological  examination  has  made  this 
new  method  of  investigation  very  practical,  putting  it,  as  it 
were,  within  the  reach  of  everyone.  The  perfecting  of  the 
instruments,  simplicity  of  manipulation  and  the  better  pro- 
duction of  X-ray  tubes  have  changed  a  process  of  examina- 
tion regarded  at  first  as  a  mere  curiosity  into  a  useful  sci- 
entific and  practical  method.  Those  who  have  once  made 
use  of  it  cannot  dispense  with  it,  and  the  time  is  coming  when 
the  information  furnished  by  radiological  examination  will 
be  as  indispensable  as  that  obtained  by  means  of  the  steth- 
oscope. In  fact,  radiology  (exclusively  surgical  in  its  be- 
ginning and  used  in  examination  of  fractures  and  the  search 
for  foreign  bodies)  has  gradually  extended  its  province  in  an 
extraordinary  manner.  Like  all  methods  of  any  value,  it 
rapidly  grew  and  is  growing  every  day.  Cautiously  used  by 
Professor  Bouchard  in  examining  the  pleura  and  lungs,  it 
has  now  become  truly  medical.  It  has  entered  the  physiolog- 
ical and  pathological  study  of  all  the  important  organs,  and 
recently  Vaquez  and  Bordet  have  demonstrated  its  value  in 
the  study  of  the  heart  and  aorta,  while  Beclere  has  pointed 
out  all  that  may  be  expected  in  exploring  the  digestive  tract. 

FAVORABLE  CONDITIONS  FOR  EXAMINATION;  OF  THE  THORAX 

The  Roentgen  rays  penetrate  solid  bodies.  It  is  to  this 
special  physical  property  that  they  owe  all  their  value,  but 
the  penetration  is  not  uniform;  it  varies  on  account  of  the 
quality  of  the  rays  emitted  and  especially  on  account  of  the 

XV 


xvi  INTRODUCTION 

density  of  the  bodies  penetrated.  A  collection  of  bodies  of 
dift'erent  densities  will  give,  then,  on  the  radioscopic  screen  a 
series  of  shadows  varying  in  value,  and  this  variation  will  be 
the  more  marked  the  greater  the  difference  in  specific  gravity 
of  the  bodies  examined.  From  these  facts  it  is  easy  to  see 
that  the  thorax  presents  most  favorable  conditions  for 
examination.  The  lungs  filled  with  air  form  on  each  side 
of  the  thorax  two  organs  of  very  light  density  which  are  seen 
on  the  radioscopic  screen  as  two  clear  areas  on  which  the 
adjacent  organs  of  a  much  greater  density  stand  out  re- 
markably. In  this  manner  the  contours  of  the  heart  and 
the  aorta,  made  more  opaque  by  the  large  quantity  of  blood 
they  contain,  appear  clearly,  as  well  as  the  costal  grill,  the 
outline  of  the  sternum  and  vertebral  column,  made  more 
dense  by  their  bony  structure  and  their  richness  in  mineral 
salts. 

On  the  other  hand,  the  slightest  pathological  lesion  of  the 
pulmonary  tissue  bringing  about  an  appreciable  modifica- 
tion in  the  density  of  the  parenchjTna  appears  as  an  abnor- 
mal shadow  on  the  screen  which  will  easily  attract  the 
physician's  attention.  In  this  way  the  most  favorable  con- 
ditions are  realized  for  the  physiological  and  anatomical 
examination  of  the  thorax  by  Roentgen  rays. 

IMPORTANCE  OF  THIS  EXAMINATION 

The  importance  of  this  examination  is  considerable,  par- 
ticularly to  the  pleuro-pulmonary  organs,  which  are  all  that 
concerns  us  here.  By  this  process  new  evidence  will  be  ob- 
tained very  different  from  that  furnished  b}'-  other  methods 
but  which  will  be  added  to  it  and  increase  in  large  propor- 
tion the  resources  of  clinical  investigation. 

Whereas  up  to  the  present  time  auscultation  and  palpation 
have  played  the  primary  part,  visual  inspection  having 
been  content  with  simply  observing  the  form  and  contours 
of  the  blood-vessels  without  noting  anything  of  their  con- 
tents, visual  observation  in  medicine  now  takes  on  a  value 
as  great  as  that  which  it  has  in  actual  life.    The  physician 


INTRODUCTION  xvii 

is  no  longer  blind  and  he  must  use  his  eye  as  well  as  his  finger 
and  his  ear  to  perfect  his  practice.  Thanks  to  the  Roentgen 
rays  the  physician  is  now  easily  able  to  see  through  the 
thoracic  wall  to  the  deep-seated  organs  which  hitherto  were 
hidden;  their  functioning  and  outline  can  be  observed  and 
their  minute  structure  analyzed.  At  once  the  superiority  of 
this  method  supersedes  all  others,  for  palpation  and  ausculta- 
tion give  information  only  as  to  the  condition  of  those  organs 
which  are  close  to  the  thoracic  wall;  auscultation  reveals 
only  lesions  superficial  enough  to  transmit  to  the  ear  per- 
ceptible sounds,  while  the  eye  can  observe  lesions  that  are 
concealed  in  the  deeper  tissues.  No  method  of  exploration 
can  determine  as  well  as  radiological  examination  the  topog- 
raphy of  pleuro-pulmonary  lesions.  Their  extent,  their 
localization  in  difficult  cases  make  what  Claude  Bernard  has 
aptly  called  "el  living  autopsy." 

No  other  method  of  exploration  demonstrates  so  clearly 
and  simply  the  functions  of  the  heart  and  lungs,  which  are  of 
so  much  importance.  It  shows  without  the  cardiograph  the 
pulsations  of  the  auricles  and  ventricles  and  the  aorta.  It 
estimates  without  the  spirometer  the  respiratory  value  of 
the  lungs;  shows  the  movements  of  the  diaphragm,  the  inter- 
costal spaces  and  displacement  of  the  mediastinum  in  in- 
spiration and  expiration. 

NECESSITY  OF  COMBINED  MEDICAL  EXAMINATION 

The  radiologist  must  be  a  physician.  This  method  of 
examination  should  not  be  emploj^ed  alone  and  take  the 
place  of  others.  That  would  be  a  grave  mistake.  If  it  is 
more  brilliant  than  the  older  method,  it  is  not  so  well  tried 
out  and  should  be  assisted  by  the  older  methods. 

In  fact,  sight  is  not  everything,  but  it  is  necessary  to  in- 
terpret what  is  seen  and  to  draw  conclusions  useful  for  a 
diagnosis.  The  difficulty  of  interpretation  demands  a  very 
accurate  knowledge  of  anatomy,  physiology  and  pathology 
and  consequently  the  radiologist  must  be  a  physician.  The 
radiologist  must  have  a  well-grounded  knowledge  of  the 


xviii  INTRODUCTION 

development  and  progress  of  disease  and  the  complications 
which  maj'  arise.  It  is  only  on  these  conditions  that  useful 
medical  work  can  be  done  and  the  serious  errors  of  inter- 
pretation avoided  which  will  inevitably  occur  without  a 
thorough  medical  education  on  the  part  of  the  radiologist. 

Radiological  examination  shows  on  the  screen  or  plate 
only  lines  and  shadows — black  and  white.  It  shows  the 
forms,  extent,  location,  degree  of  opacity  of  these  shadows  as 
well  as  their  relation  to  different  organs.  It  gives  no  informa- 
tion of  their  nature,  their  anatomical  value  or  development. 
Information  lacking  to  the  radiologist  can  be  furnished  by 
physician,  patient,  family  history,  study  of  the  development 
of  his  disease,  and  finally  and  especially,  by  a  complete 
physical  examination,  investigation  of  functional  disturb- 
ances, analysis  of  urine,  sputum,  etc. 

A  wise  interpretation  can  be  made  only  in  the  light  of  all 
these  facts  without  neglecting  any.  It  must  then  be  decided 
which  should  have  precedence  and  why.  In  short,  after  a 
careful  and  detailed  analysis,  a  synthesis  ought  to  be  made. 
In  that  diagnosis  consists. 

In  certain  cases  radiological  examination  may  be  con- 
clusive and  may  totally  change  the  superficial  diagnosis. 
In  other  cases  it  will  simply  confirm  the  diagnosis.  Even 
when  a  'priori  it  seems  useless,  it  ought  not  to  be  neglected, 
as  it  is  often  in  that  case  most  interesting  and  furnishes  to 
the  physician  most  unexpected  data.  It  is  always  the  physi- 
cian, however,  who  ought  to  decide  in  the  last  analysis. 

The  physician  ought  to  become  interested  in  radiology. 
If  the  radiologist  ought  to  be  a  physician,  it  would  be  well 
also  for  the  physician  to  be,  in  a  less  degree,  a  radiologist. 

It  would  be  very  useful  to  everyone  if  the  bond  between 
physician  and  specialist  were  closer.  Every  physician  ought 
to  be  interested  in  this  new  method,  to  know  the  elementary 
principles  and  learn  to  read  the  chest  on  the  screen  or  plate. 
If  he  cannot  personally  examine  the  patient,  he  ought  to 
assist.  The  radiologist  will  thus  be  furnished  with  the  facts 
he  has  not  always  time  to  collect.    He  will  discuss  with  the 


INTRODUCTION  xix 

physician  the  interpretation  of  the  images,  and  the  diagnosis 
will  gain  in  accuracy. 

Radiology  has  become  a  useful  science  and  will  become 
more  so  every  day,  provided  there  is  greater  collaboration 
between  physician  and  radiologist. 


PART  I 
METHODS  OF  EXAMINATION 


CHAPTER  I 
RADIOSCOPIC  EXAMINATION  OF  THE  THORAX 

NORMAL  Images. — Before  attempting  to  interpret 
pathological  changes  it  is  absolutely  essential  to  un- 
derstand thoroughly  the  normal  thorax.  As  has  already 
been  seen,  the  number  of  pictures  is  unlimited.  They  vary 
with  the  position  of  the  patient,  the  height  of  the  tube,  the 
quantity  and  quality  of  the  rays.  It  would  be  impossible 
to  describe  all  of  them  and  moreover  quite  useless.  But 
among  these  positions  there  are  a  certain  number  which  are 
constantly  used  and  which  may  be  called  classic  or  fun- 
damental positions.  These  are  as  follows :  frontal  or  anterior, 
dorsal  or  posterior,  left  transverse,  right  transverse,  right 
anterior  oblique,  and  left  posterior  oblique. 

Frontal  or  anterior  position. — In  this  the  patient  faces  the 
screen  and  is  exposed  to  the  Roentgen  rays  from  back  to 
front.  This  position  is  one  of  the  best  for  obtaining  a  view 
of  the  whole  of  the  thorax.  The  image  of  the  thorax  is  pro- 
duced on  the  screen  as  a  rather  large  median  shadow  of 
irregular  form,  on  each  side  of  which  are  two  large,  clear 
areas  which  constitute  the  lungs. 

The  median  shadow  is  formed  by  the  superposition  of  the 
vertebral  column,  the  sternum  and  all  the  organs  of  the 
mediastinum,  particularly  the  large  vessels :  aorta,  pulmonary 
artery,  venae  cavaB.  At  the  base  the  shadow  is  quite  mark- 
edly enlarged  on  the  left  side  because  of  the  heart. 

The  form  of  this  median  shadow  is  quite  regularly  rec- 
tilinear in  the  upper  two- thirds  of  its  right  border;  the 
middle  third  corresponds  to  the  superior  vena  cava;  in  the 
lower  third  it  presents  quite  often  a  rounded  dilatation  which 
corresponds  to  the  contour  of  the  right  auricle.  Its  left 
border  is  composed  of  three  successive  arches.     The  first 

1 


2 


RADIO-DIAGNOSIS:  PLEURAE 


of  these  is  the  aortic  arch,  situated  at  the  very  top,  just 
below  the  internal  border  of  the  clavicle.  The  middle  arch 
corresponds  to  the  pulmonarj^  artery;  the  inferior  arch, 
much  the  most  important,  forms  the  contour  of  the  left 
ventricle.  All  these  arches  are  animated  by  perceptible 
pulsations,  at  times  very  distinct,  which  show  clearly  the 
alteration  between  the  pulsations  of  the  ventricle  and  those 
of  the  pulmonary  artery  and  the  aorta. 


14 
16 
4 

J 

..15 
'17 

^?^ 

/ 

7 
..3 

I 

"  / 

X. 

6.. 

5 

\ 

72  ... 
10... 

8.. 

. 

...9 

f 

...13 
...11 

Fig.  3.     FRONTAL  OR  ANTERIOR  POSITION 
1.  Aortic  arch.     2.  Pulmonary  arch.     3.  Ventricle  arch.     4.  Border  of  the  su- 
perior vena  cava.     5.  Right  auricle.     6.  Shadow  of  right  hilus.     7.  Shadow  of 


left  hilus.  8  and  9.  Cardio-diaphragmatic  sinuses, 
matic  sinuses.  12  and  13.  Convexity  of  diaphragm. 
16  and  17.  Clavicles. 


10  and  11.  Costo-diaphrag- 
14  and  15.  Apices  of  lungs. 


With  this  median  shadow  must  be  included  the  shadow 
of  the  hilus  of  the  lung,  visible  especially  at  the  right  because 
at  the  left  it  is  partly  covered  by  the  shadow  of  the  heart. 
This  shadow,  which  is  far  less  dense,  is  detached  from  the 
median  shadow  toward  its  center  and  separated  from  it  by 
a  narrow,  clear  space.  The  form  is  a  crescent,  of  which  the 
lower  horn  is  a  little  more  elongated  and  prolonged  obliquely 
downward  and  to  the  right.  The  significance  of  this  shadow 
has  been  much  discussed.  Among  the  organs  which  con- 
stitute the  hilus  it  is  probable  that,  in  the  normal  state, 


RADIOSCOPIC  EXAMINATION  OF  THE  THORAX     3 

these  are  especially  the  vascular  organs:  the  pulmonary 
arteries  and  veins  which  contribute  to  its  formation;  the 
bronchi  seem  to  play  only  an  unimportant  par't.  In  the 
pathological  condition  this  shadow  is  enlarged,  elongated 
and  very  perceptibly  thickened.  It  appears  then  that  its 
composition  becomes  more  complex  and  that  the  hyper- 
trophied  and  inflamed  glands,  bronchic  and  peribronchic 
sclerosis  add  perceptibly  to  the  opacity  of  the  vascular  el- 
ement. 

The  lung  spaces  are  made  up  of  two  large,  sjonmetrical 
clear  areas,  situated  on  each  side  of  the  median  shadow,  the 
contours  of  which  they  aid  in  defining.  The  shadow  of  the 
ribs  is  also  very  clearly  seen,  symmetrically  arranged, 
crossing  obliquely  the  clear  zone  from  top  to  bottom  and 
from  without  inward  and  forming  the  costal  grill. 

Each  lung  is  triangular  in  form.  The  upper  part  is  nat- 
urally separated  from  the  rest  by  the  shadow  of  the  clavicle 
and  the  portion  thus  circumscribed  corresponds  to  the  pic- 
ture of  the  apex  of  the  lung.  The  base  is  limited  by  a  mov- 
able shadow  with  sharply  defined  contour,  convex  in  form. 
It  is  the  diaphragmatic  dome  which  falls  on  inspiration  and 
rises  on  expiration.  The  extent  of  this  movement  furnishes 
excellent  indications  of  the  respiratory  capacity  of  the  lungs; 
normally,  it  ought  to  be  equal  on  both  sides. 

The  level  of  the  diaphragmatic  dome  is  not  the  same  on  the 
right  as  on  the  left.  The  liver,  in  raising  the  diaphragm, 
elevates  its  outline  in  a  marked  manner.  The  convexity  of 
this  outline  helps  to  form,  together  with  the  adjacent 
shadows,  a  sort  of  cul-de-sac  or  sinus  which  is  very  important 
to  recognize. 

The  costodiaphragmatic  sinuses  correspond  to  the  external 
extremities.  These  are  largest  and  deepest  and  their  presence 
ought  always  to  be  looked  for.  Their  diminution  or  their 
disappearance  always  indicates  a  pathological  process.  At 
the  internal  extremities  are  two  other  smaller  sinuses  called 
the  cardiodiaphragmatic  sinuses.  Their  disappearance  is 
usually  caused  by  a  pleural  or  pericardial  process. 


4  RADIO-DL\GNOSIS:  PLEUR.E 

In  women,  the  breasts  cast  two  symmetrical  shadows 
over  the  lower  part  of  the  thorax,  sometimes  obscuring  the 
bases  and  more  or  less  completely  effacing  the  contour  of 
the  diaphragm  and  the  costodiaphragmatic  sinus.  They 
should  not  be  taken  for  pathological  shadows.  If  the  breasts 
are  raised  upward  and  outward  the  normal  thoracic  clear- 
ness reappears. 

The  importance  of  examination  in  the  frontal  anterior 
position  is  thus  demonstrated.  It  gives  a  view  of  the  whole 
of  the  thorax;  it  permits  one  to  become  orientated  so  that 
it  will  be  possible  to  complete,  in  the  other  positions,  the 
study  of  those  organs  which  have  especially  attracted  the 
attention  of  the  observer. 

Dorsal  or  posterior  position. — In  this  position  the  patient's 
back  is  to  the  screen  and  the  rays  penetrate  from  front  to 
back.  The  image  obtained  is  analogous  to  that  of  the  in- 
verse frontal  position.  It,  however,  differs  from  it  in  cer- 
tain details.  The  outlines  of  the  median  shadow  and  of  the 
heart  are  more  deformed.  The  heart  and  the  aorta  being 
further  from  the  screen,  their  projection  is  magnified.  The 
shadow  of  the  hilus  of  the  lungs  is  less  clearly  visible.  On 
the  other  hand,  the  scapula  shadow  stands  out  more  clearly 
and  the  costodiaphragmatic  sinuses  and  the  respiratory 
movements  of  the  diaphragm  are  perfectly  distinct. 

Transverse  position. — The  patient  is  turned  ninety  degrees 
so  that  either  the  right  or  the  left  side  is  to  the  screen.  There 
are,  then,  two  transverse  positions:  the  right  transverse,  in 
which  the  patient  is  exposed  to  the  rays  from  left  to  right, 
and  the  left  transverse,  in  which  he  is  exposed  from  right 
to  left. 

In  the  first  of  these  positions  the  liver  comes  in  contact 
with  the  screen;  it  will  therefore  be  useful  for  the  examina- 
tion of  this  organ — the  determination  and  localization  of 
an  abscess  or  hydatic  cyst.  In  the  second  position  it  is  the 
heart  which  comes  nearest  to  the  screen  and  there  can  be 
obtained  in  this  manner  interesting  data  regarding  the 
anterio-posterior  diameter  which  it  is  impossible  to  appre- 


RADIOSCOPIC  EXAMINATION  OF  THE  THORAX     5 

ciate  in  the  dorsal  and  frontal  positions.  The  thoracic 
portion  of  the  descending  aorta  can  also  be  seen  very  well, 
and  it  can  be  definitely  ascertained  whether  an  aneurysm, 
already  brought  out  by  the  examination  in  the  other  posi- 
tions, involves  this  portion  of  the  vessel. 

Oblique  positions. — These  positions  are  innumerable,  but 
two  are  especially  well  known  because  they  are  considered 
the  classic  positions  for  the  examination  of  the  aortic  arch 
and  the  oesophagus. 

Right  anterior  oblique  position :  Examination  of  the  aortic 
arch.  In  order  to  obtain  this  position,  from  the  frontal 
position,  turn  the  patient  slowly  f  om  right  to  left  in  such  a 
way  as  to  bring  the  right  nipple  vertical  line  in  contact  with 
the  screen.  He  will  thus  be  penetrated  from  back  to  front 
and  from  left  to  right.  In  this  way  the  median  shadow  is 
shut  out,  and  looking  at  the  screen,  the  observer  will  see 
successively  the  shadow  of  the  vertebral  column  pass  to 
the  left  while  that  of  the  sternum,  scarcely  apparent,  de- 
viates toward  the  right.  Between  the  two  the  shadow  of  the 
aorta  appears  clearly  and,  more  particularly,  that  of  the 
aortic  arch.  Between  the  aorta  and  the  vertebral  column 
is  a  clear  space,  narrow  and  elongated,  which  is  called  the 
median  clear  space;  the  middle  of  this  space  is  crossed  by  a 
gray  shadow  more  or  less  dense,  due  to  the  shadow  of  the 
hilus  of  the  lung.  This  position  is  therefore  perfect  for  the 
study  of  the  aorta,  of  the  mediastinum,  from  which  all  the 
organs  are  separated,  and  in  an  accessory  way,  for  the  study 
of  the  hilus  of  the  lungs  and  the  search  for  tracheo-bronchial 
adenopathy. 

Left  posterior  oblique  position:  Examination  of  the 
oesophagus.  This  position  is  obtained  starting  from  the 
dorsal,  by  turning  the  patient  from  right  to  left  until  the 
left  scapula  comes  in  contact  with  the  screen.  The  rays  will 
then  penetrate  from  front  to  back  and  from  right  to  left. 
The  dissociation  of  the  median  shadow  will  be  made  in  an 
analogous  manner  but  gives  an  inverse  image  of  it.  A  clear 
space  becomes  visible  from  top  to  bottom  on  the  left  border 


6  RADIO-DIAGNOSIS:  PLEUR.E 

of  the  vertebral  shadow,  which  is  the  oesophagus.  The 
thoracic  tract  of  the  oesophagus  can  be  entirely  studied  and 
its  general  shape  and  functional  capacity  verified. 

The  study  of  these  fundamental  positions  ought  never  to 
be  neglected,  but  it  is  very  important  to  complete  the  exam- 
ination by  studying  a  whole  series  of  intermediary  positions. 
The  radiologist  can  never  obtain  too  many  images  or  famil- 
iarize himself  too  thoroughly  with  all  their  aspects  under 
the  most  varied  angles  of  incidence  and  from  all  the  positions 
should  learn  to  verify  his  findings.  In  difficult  cases  a  true 
interpretation  can  sometimes  be  made  from  a  small  detail 
obtained  in  some  one  position. 

Procedure. — In  all  these  cases  it  is  best  to  make  at  first 
a  complete  examination  followed  by  an  examination  in  de- 
tail. Always  begin  by  studying  frontal  and  dorsal,  then 
fundamental  oblique  and  transverse  positions  and  finally  a 
whole  series  of  intermediary  positions. 

Complete  Examination. — In  the  complete  examination 
an  attempt  will  be  made  to  ascertain  whether  the  images 
are  quite  normal  in  all  positions,  whether  they  have  kept 
their  general  form  and  regularity  of  contour.  In  the  frontal 
and  dorsal  positions  the  comparison  of  the  right  and  left 
sides  will  be  made.  The  symmetry  or  irregularity  of  the 
forms,  contours  and  dimensions  will  be  looked  for, — the  con- 
formity or  the  difference  in  clearness  as  well  as  the  mobility 
of  the  organs  and  their  regularity  in  functioning. 

Detailed  Examination. — An  examination  in  detail  will 
then  be  taken  up,  and  it  should  be  kept  in  mind  always  that 
the  organ  one  wishes  to  examine  ought  to  be  placed  as  near 
as  possible  to  the  screen  in  order  to  avoid  deformation.  The 
diaphragm  will  be  used  in  order  to  concentrate  the  light 
at  the  special  point  to  be  studied  so  that  contours  will  ap- 
pear more  clearly.  Finally,  the  quality  of  the  rays  ought 
to  be  varied  in  order  to  bring  out  its  structure,  to  dissociate 
shadows  of  different  density  and  thus  to  have  an  anatomical 
conception  of  it  as  clear  as  possible. 

In  the  study  of  the  pleuro-pulmonary  affections  which  is 


RADIOSCOPIC  EXAMINATION  OF  THE  THORAX     7 

the  subject  of  this  book,  the  attention  of  the  observer  ought 
to  be  directed  more  especially  to  a  certain  number  of  points. 
He  ought  to  ascertain  particularly  the  condition  of  the  apices, 
hilus,  sinuses,  interlobes,  and  carefully  examine  the  di- 
aphragmatic respiration. 

Examination  of  the  apices. — In  general  the  apices  of  the 
lungs  are  less  clear  than  the  bases;  their  functioning  is  less 
active,  the  air  penetrating  there  in  less  quantity.  This 
diminution  of  clearness  is  still  more  accentuated  in  obese  or 
in  muscularly  developed  individuals.  It  is  not  necessary  to 
pay  much  attention  to  a  diminution  in  clearness  of  the  apices 
provided  it  is  equal  and  symmetrical  on  both  sides.  But 
if  this  diminution  is  unilateral,  it  becomes  immediately  more 
important.  It  is  important  to  make  use  of  the  diaphragm 
and  to  vary  the  quality  of  the  rays. 

Examination  of  the  hilus. — The  shadow  of  the  hilus  de- 
serves also  special  study.  When  it  is  normal,  it  does  not 
signify  that  the  pleuro-pulmonary  tissues  are  intact;  but 
when  it  is  abnormal — more  extensive  and  denser — there  most 
often  exists  a  pleuro-pulmonary  reaction  requiring  investiga- 
tion. 

Examination  of  the  interlobes. — It  is  useful  to  determine 
the  condition  of  the  interlobes.  A  shadow  at  this  level  always 
indicates  an  old  or  recent  pleural  process.  To  make  this 
evident  it  is  necessary  not  only  to  employ  the  diaphragm  and 
to  vary  the  quality  of  the  rays,  as  in  the  hilus  or  apex,  but 
also  to  modify  the  height  of  the  tube,  as  Beclere  has  pointed 
out.  In  the  dorsal  position  the  tube  should  be  raised  to  the 
height  of  the  head ;  in  the  frontal  position,  it  should  be  low- 
ered to  the  level  of  the  pelvis.  In  this  way  the  normal  rays 
penetrate  the  interlobe  in  its  greatest  thickness  and  the  best 
conditions  are  found  for  obtaining  an  image.  (See  Inter- 
lobar Pleurisy,  Sclerosis  of  the  Interlobe.) 

Examination  of  the  sinuses. — The  costodiaphragmatic 
sinuses  ought  to  be  the  subject  of  serious  examination;  they 
ought  to  be  studied  separately  and  comparatively.  The  in- 
ferior angle  of  the  sinus  ought  always  to  be  acute  and  deep; 


8  RADIO-DIAGNOSIS:  PLEUR.E 

it  ought  to  increase  and  clear  on  inspiration,  to  partly  fill  and 
darken  on  expiration.  If  it  appears  abnormal,  one  should 
compare  it  with  the  opposite  side,  bearing  in  mind  the  mod- 
ifications which  may  be  produced  on  the  right  by  the  proxim- 
ity of  the  liver,  on  the  left  by  the  stomach  according  to  its 
state  of  vacuity  or  of  repletion. 

Examination  of  the  diaphragm  and  respiration. — Finally, 
the  study  of  respiratory  movements  is  particularly  important. 
It  should  include  the  lung,  ribs  and  diaphragm. 

Lungs. — It  is  known  that  the  pulmonary  image  becomes 
decidedly  illuminated  on  inspiration  and  darkened  on  expira- 
tion. This  phenomenon  is  particularly  visible  towards  the 
bases.  This  clearness  ought  to  be  carefully  compared;  a 
defect  in  illumination  on  one  side  is  related  to  a  defect  in 
pulmonary  expansion  on  the  same  side;  and  it  will  be  nec- 
essary to  investigate  the  cause  of  it. 

Ribs. — It  is  equally  useful  to  compare  the  image  of  the 
costal  grill  on  each  side.  A  diminution  of  the  intercostal 
spaces  coincident  with  greater  obliqueness  in  direction  and 
a  narrowing  of  the  pulmonary  field  on  the  same  side  suggests 
a  collapse  of  the  thoracic  wall  such  as  is  observed  after 
pleurisy. 

Diaphragm. — Finally,  the  greatest  attention  should  be 
given  to  the  study  of  the  functioning  of  the  respiratory 
pump,  of  which  the  diaphragmatic  dome  constitutes  the 
piston.  It  is  necessary  to  see  whether  the  course  of  the 
piston  is  sufficiently  extended,  is  equal  on  both  sides,  and 
whether  the  movements  are  regular  and  continuous  or  irreg- 
ular and  jerky.  The  slightest  trouble  in  the  functioning  of 
this  important  apparatus  assumes  at  once  a  grave  significance 
that  an  experienced  radiologist  ought  never  to  neglect. 

It  is  only  after  having  made  use  of  all  these  examinations, 
as  a  whole  and  in  detail,  that  the  observer  from  all  these 
findings  can  affirm  whether  the  thorax  he  has  just  examined 
is  normal  or  pathological. 

Abnormal  Images. — When  examination  has  shown  that 
an  abnormal  image  is  present,  it  ought  to  be  studied  and 


RADIOSCOPIC  EXAMINATION  OF  THE  THORAX     9 

all  deductions  should  be  drawn  that  may  be  useful  for  di- 
agnosis. 

A  complete  diagnosis  from  a  radioscopic  examination 
alone  ought  never  to  be  made  at  once,  even  in  the  most 
favorable  cases.  It  is  always  necessary  to  have  clinical  data 
and  to  endeavor  to  make  it  agree  with  the  radioscopic  exam- 
ination. 

The  radiological  study  of  abnormal  shadows  gives  only 
their  form,  contours,  localization,  extent,  multiplicity,  the 
value  or  density  of  these  shadows,  and  their  relation  with 
adjacent  organs. 

Let  us  take  the  most  favorable  cases — those  in  which  the 
form  and  contours  of  the  abnormal  shadow  are  entirely 
characteristic.  Two  typical  examples  may  be  chosen: 
Given  a  patient  in  the  examination  of  whom  is  seen  on  one 
side  of  the  thorax  a  very  dense  base  limited  by  a  mobile 
horizontal  line,  more  or  less  suddenly  displaced  with  each 
motion  but  always  remaining  horizontal  in  the  different 
changes  of  position.  It  is  certainly  the  line  of  fluid  level. 
Above  this  dark  zone  there  is  a  very  clear  zone,  due  probably 
to  the  presence  of  a  collection  of  gas  over  the  fluid.  This 
lesion  is  often  completely  obscured,  difficult  to  detect  clin- 
ically, and  the  radioscopic  examination  in  such  cases  may 
therefore  be  of  great  assistance  in  directing  diagnosis;  but 
it  cannot  determine  it  entirely.  In  fact,  it  cannot  indicate 
whether  it  is  a  question  of  a  hydro  or  of  a  pyopneumothorax, 
and  it  only  shows  very  imperfectly,  if  at  all,  its  cause  and  its 
origin.  The  rest  of  the  information  should  be  obtained 
clinically. 

Given  another  patient  who  shows  in  the  thorax  an  ex- 
tended, opaque  shadow  of  regularly  spherical  form,  with 
sharply  defined  contours.  The  form  and  contours  of  the 
shadow  are  characteristic,  yet  the  diagnosis  is  not  evident. 
It  may  be  a  question  of  a  mediastinal  tumor,  an  aneurysm 
of  the  aorta,  or  a  thoracic  cyst.  Suppose  that  by  radioscopic 
examination  a  study  is  made  of  the  form,  relation  and 
topography,  the  first  two  hypotheses  are  eliminated  and  the 


10  RADIO-DIAGNOSIS:  PLEUR.E 

existence  of  a  thoracic  cj^st  is  affirmed.  It  will  be  impossible 
most  often  to  assert  whether  the  cyst  is  dermoid  or  hydatid. 

Beside  its  form  and  contours  an  abnormal  shadow  is  also 
characterized  by  its  localization.  A  denseness  localized  in 
the  apex  suggests  pulmonary  tuberculosis.  But  this  localiza- 
tion may  also  be  seen  in  certain  cases  of  pneumonia,  in  cer- 
tain cases  of  cancer  of  the  lung,  etc.  A  localized  density  at 
a  base  suggests  a  sequela  of  pleurisy  but  may  be  due  to  other 
causes. 

The  extent  of  an  abnormal  shadow  is  equally  important  to 
ascertain.  A  very  extended  shadow  occupying  all  one  side 
of  the  thorax,  accompanied  by  a  displacement  of  the  me- 
diastinum calls  to  mind  pleurisy  with  effusion;  but  certain 
pulmonary  processes  may  also  produce  this  image  and  often 
it  is  produced  bj^  a  combination  of  the  two  processes — pleural 
and  pulmonary. 

The  multiplicity  of  abnormal  shadows  is  produced  in  the 
lungs  by  chronic  pulmonary  tuberculosis  and  broncho- 
pneumonia; but  in  a  lesser  way  also  by  a  number  of  other 
affections. 

The  value  of  the  density  of  the  shadow  in  question  is  also 
of  some  importance.  An  extended,  very  opaque  and  ho- 
mogeneous shadow  will  suggest  rather  a  fluid  collection. 
Under  the  same  conditions  a  limited  shadow  will  more  often 
be  associated  with  a  gland,  a  calcified  tubercle,  or  with  a 
foreign  body. 

Finally,  a  study  of  the  relation  of  the  abnormal  shadow  with 
the  adjacent  organs  will  help  more  especially  to  bring  out 
this  or  that  organ  as  being  the  cause  of  the  formation  of  the 
shadow. 

Conclusion. — Such,  in  the  main,  are  the  facts  which  the 
radioscope  may  furnish  the  clinician.  The  physician  ascer- 
tains on  the  screen  only  the  shadows  and  light  areas  which 
constitute  normal  and  abnormal  shadows.  All  deductions 
useful  in  medicine  are  based  on  the  analysis  of  these  shadows. 
Not  all  this  information  will  be  useful,  but  if  any  one  part 
becomes  so,  it  is  enough  to  prove  the  value  of  the  method. 


RADIOSCOPIC  EXAMINATION  OF  THE  THORAX  11 

In  conclusion,  and  it  cannot  be  repeated  too  often,  final 
and  complete  diagnosis  ought  not  to  be  demanded  of  ra- 
dioscopy. That  is  not  within  its  province.  Radioscopy  is 
not  a  supernatural  science.  It  is  only  a  method  of  explora- 
tion, different  from  the  others,  perhaps  more  perfect,  whoso 
part  it  is  to  furnish  some  indication  and  interpretation  for 
diagnosis.  In  difficult  cases,  when  there  is  a  question  of 
diagnosis,  this  method  will  be  of  some  value  but  it  should 
remain  for  the  physician  to  make  final  diagnosis. 


PART  II 
RADIOLOGICAL  STUDY  OF  THE  PLEURA 

IN  the  normal  state  the  pleurae  do  not  show  on  radio- 
scopic  examination.  The  thickness  of  the  layers  being 
everywhere  the  same,  no  abnormal  shadow  is  seen  on  the 
screen;  as  for  the  pleural  cavity,  it  is  purely  potential;  the 
lung,  owing  to  its  own  elasticity,  fills  the  entire  thoracic 
cavity  and  gives  it  its  clearness. 

The  pleural  layers  are  visible  only  in  the  pathological 
state,  when  local  inflammation  has  produced  a  thickening 
of  the  wall,  or  a  fibrinous  deposit  on  its  surface  (dry  pleurisy) . 

The  pleural  cavity  is  apparent  only  when  it  is  abnormally 
filled  either  with  fluid  (pleurisy  with  sero-fibrinous  or  pu- 
rulent effusion) ;  or  with  a  gas  (pneumothorax) ;  or  with  both 
at  once  (hydropneumothorax  or  pyopneumothorax). 

Effusions  of  the  pleura  may  involve  either  the  entire 
pleural  cavity  (pleurisy  of  the  large  cavity)  or  only  a  part 
of  this  cavity.  In  that  case  the  pleurisy  is  circumscribed 
(encysted  pleurisy),  and  according  to  the  portion  of  the 
pleura  involved  it  is  known  as  interlobar,  diaphragmatic,  or 
mediastinal  pleurisy. 

The  different  pleural  manifestations  and  their  radiological 
characteristics  will  now  be  taken  up. 


13 


CHAPTER  I 
PLEURISY  OF  THE  LARGE  CAVITY 

PLEURISY  WITH  Effusion. — This  is  one  of  the  forms 
most  often  seen  clinically.  The  diagnosis  is  ordinarily 
easy  enough  by  the  means  usually  employed:  percussion, 
palpation,  auscultation.  However,  there  are  cases  where 
these  are  not  sufficient. 

Radiological  examination  may,  therefore,  under  certain 
conditions  help  determine  the  diagnosis;  but  it  will  furnish, 
above  all,  considerable  information  on  the  development  of 
the  disease,  increase  or  decrease  of  effusion,  compression  and 
displacement  of  the  surrounding  organs,  the  re-establishment 
of  pulmonary  functions;  in  general,  it  will  serve  to  throw 
light  on  the  prognosis. 

Radioscopic  examination  of  pleurisy  was  first  practised 
by  Bouchard  in  1896.  Bergonie  and  Carriere  in  1899  did 
work  based  on  eleven  observations.  Bar j  on  took  up  the 
question  in  1904  with  his  colleague  P.  Courmont  at  the 
"Societe  Medicale  des  Hopitaux  de  Lyon"  and  in  Fayard's 
thesis  (Lyon,  1904),  called  attention  particularly  to  the 
oblique  direction  of  the  fluid  level,  in  relation  to  the  curve 
of  Damoiseau,  which  the  radioscopic  examination  explained. 

General  Appearance  of  the  Thorax. — When  the 
thorax  of  a  patient  with  pleurisy  of  the  large  cavity  is 
examined  on  the  screen,  one  is  impressed  with  the  almost 
total  obscurity  of  the  diseased  side,  while  the  normal  side 
retains  all  its  clearness.  This  obscurity  is  nearly  uniform, 
but  more  intense,  however,  obliquely  from  the  base.  At  this 
level  it  becomes  impossible  to  distinguish  the  contour  of  the 
diaphragm,  as  the  respiratory  movements  are  abolished,  or 
the  lateral  ''cul-de-sac,"  which  is  completely  effaced  by  the 
effusion.    At  the  top  a  clearness  persists  which  is  the  more 

15 


16 


RADIO-DIAGNOSIS:  PLEURAE 


decreased  and  obscured  the  more  abundant  the  effusion. 
Under  the  pressure  of  the  fluid  a  lateral  deformation  is  pro- 
duced corresponding  to  the  displacement  of  the  mediastinum 
and  of  the  heart.  This  displacement  is  shown  on  the  screen 
by  a  triangular  enlargement  of  the  median  shadow,  the  size 
of  which  increases  progressively  from  top  to  bottom  and 
stands  out  against  the  clear  background  of  the  normal  side. 

Upper  limit  of  the  effusion:  Appearance  of  the  apex. — The 
upper  limit  of  the  effusion  does  not  show  a  sharply  defined 
outline  in  pleurisy.    The  opacity  diminishes  gradually;  and 


Fig.  4.     PLEURISY  LEFT  SIDE 

Displacement  of  heart  and  mediastinum,  lowered  position  of  diaphragm.    Upper 
limit  of  efifusion  slopes  downward  from  without  inward. 

little  by  little,  through  a  series  of  transitions,  one  passes 
imperceptibly  from  shadow  to  light  without  being  able  to 
exactly  say  where  one  stops  and  the  other  begins.  However, 
by  studying  it  carefully  and  using  a  lead  diaphi'agm,  one 
can  determine  this  upper  outline  and  define  its  form. 

The  difficulty  of  this  interpretation  explains  up  to  a 
certain  point  the  difference  of  opinion  of  authors  who  have 
ascribed  to  this  line  sometimes  a  convex,  sometimes  a  con- 
cave, sometimes  a  horizontal  form.  It  is  fair  to  add  in 
explanation  that  this  form  is  modified  quite  appreciably 
according  to  the  height  of  the  effusion,  so  that  the  variation 


PLEURISY  OF  THE  LARGE  CAVITY  17 

in  their  descriptions  may  perhaps  be  due  to  the  fact  that 
their  observations  were  made  under  different  phases,  either 
of  increase  or  decrease  of  the  pleurisy. 

In  an  effusion  of  moderate  amount  this  line  takes  an 
oblique  direction  from  the  top  downward  and  from  without 
inward;  commencing  from  without  at  the  apex  of  the  axilla 
and  ending  inwards  towards  the  hilus  of  the  lung.  This 
position  corresponds  to  the  so-called  curve  of  Damoiseau. 
This  is  the  most  common  form  and  the  one  which  ought  to 
call  to  mind  at  once  a  pleural  effusion. 


Fig.  5.     PLEURISY  OF  THE  LARGE  CAVITY 

Modifications  of  the  fluid  curve.  H:  hilus  region.  1  and  2:  oblique  line,  curve 
of  Damoiseau.    3  and  4:  broken  lines,  subsiding  effusion. 

When  the  pleurisy  increases,  the  light  triangle  retained 
at  the  apex  by  this  curve  diminishes  little  by  little  until  it 
disappears,  and  there  may  occur  a  time  when  the  obscurity 
becomes  complete  throughout  the  hemithorax.  On  the  con- 
trary, if  the  effusion  decreases,  the  line  is  lowered;  is  trans- 
formed at  first  into  a  broken  line  and  tends  more  and  more 
towards  the  horizontal.  Even  when  the  clearness  of  the 
apex  is  retained,  it  is  always  perceptibly  less  than  that  of 
the  opposite  side.  This  diminution  does  not  signify  that 
there  are  lesions  in  the  pulmonary  parenchyma,  but  only  a 
functional  inhibition  of  the  compressed  lung,  in  which  the 


18  RADIO-DIAGNOSIS:  PLEURA 

penetration  of  the  air  is  much  reduced  on  account  of  the 
suppression  of  the  diaphragmatic  respiration  on  the  side  of 
the  effusion. 

Curve  of  Damoiseau. — It  is  a  principle  that  every  large 
effusion  of  the  pleura  which  decreases  shows  this  decrease  on 
radioscopic  examination  by  a  gradual  lowering  of  the  line 
of  the  oblique  shadow,  which  always  remains  directed  from 
above  do^^^lward  and  from  without  inward. 

This  statement  is  confirmed  by  clinical  findings.  When 
pleurisy  decreases,  there  always  reappears  sonority,  fremitus 
and  respiration  in  the  paravertebral  triangle  situated  be- 
tween the  scapula  and  the  vertebral  column.  At  this  time 
the  effusion  is  circumscribed  by  a  parabolic  curved  line 
which,  starting  from  the  apex  of  this  triangle,  rises  toward 
the  axilla  and  descends  on  the  anterior  wall,  reaching  the 
sternum  obliquely  towards  the  hilus  of  the  lung,  so  that  it 
comes  back  almost  to  the  same  level  from  which  it  started. 
This  is  the  so-called  curve  of  Damoiseau. 

The  existence  of  this  curve  is  proved  by  clinical  and  radio- 
logical examination;  it  appears  on  the  screen  as  the  oblique 
line  that  has  just  been  described.  By  studying  this  oblique 
line,  in  the  usual  position  of  the  curve,  and  by  examining 
the  variations  and  deformations  that  it  undergoes,  such  as 
its  rise  and  fall  from  this  position,  the  cause  and  the  reason 
for  this  unusual  picture  can  be  understood. 

In  fact,  in  all  these  successive  deformations  this  oblique 
line  always  ends  inward  towards  a  fixed  point  which  is  the 
hilus  of  the  lung. 

Therefore,  if  we  study  the  progress  of  the  fluid  inversely, 
that  is  to  say  up  to  the  period  of  increase,  it  is  easy  to  under- 
stand the  formation  of  the  curve,  if  we  bear  in  mind  this 
anatomical  fact,  that  the  lung,  free  from  all  parts  in  the 
pleural  cavity,  is  only  retained  and  fixed  at  a  single  point: 
that  is  at  the  level  of  the  hilus  where  the  bronchi  and  vessels 
enter  and  at  its  inner  margin  where  the  ligament  of  the  lung 
is  attached. 

When  an  effusion  is  produced  in  the  pleura,  the  fluid, 


PLEURISY  OF  THE  LARGE  CAVITY 


19 


following  the  laws  of  gravity,  collects  at  the  base  above  the 
diaphragm.  In  proportion  as  it  increases,  it  presses  back 
the  lung  from  the  base  upward,  which,  on  account  of  its 
elasticity,  becomes  very  much  compressed.  This  goes  on  in 
this  way  until  the  level  of  the  fluid  reaches  the  region  of 
the  hilus.  At  this  point,  the  lung  being  fixed  offers  a  serious 
resistance  to  the  pressure  of  the  fluid.  Meeting  resistance 
on  the  inner  side,  the  fluid  presses  outward,  where  the  lung, 
being  free,  is  more  easily  moved;  the  fluid  increases,  infil- 


FiG.  6.    EXPLANATION  OF  THE  CURVE  OF  DAMOISEAU 
A,  B,  C.     Horizontal  sections  of  the  different  levels  of  the  thorax,  showing  the 
separation  from  the  fluid  and  its  difference  in  thickness  without  and  within. 

Fig.  6.    THE  SAME 
Superposition  of  sections  A,  B,  and  C.      Location  of  the  fluid  at  the  level  of  each 
of  them,  showing  the  formation  of  an  inclined  plane. 

trating  between  the  two  layers  of  the  pleura  and  separating 
the  lung  from  the  wall.  The  level  of  the  fluid  remains  always 
horizontal  and  its  depth  increases  more  quickly  without 
than  within,  and  this  difference  in  depth  is  seen  on  the 
screen  by  an  oblique,  dark  line  from  above  downward  and 
from  without  inward. 

In  summing  up,  three  factors  influence  the  production  of 
the  curve  of  Damoiseau: 

1st.  Gravity.    2nd.  The  relative  mobility  and  elasticity  of 


20  RADIO-DL\GNOSIS:  PLEURA 

the  lung.  3rd.  The  fixity  of  the  lung  within,  in  the  middle 
portion  by  the  hilus  and  lower  down  by  the  ligament. 

A  fourth  very  important  factor  is  necessary  to  produce 
this  curve.  In  order  to  be  seen  the  patient  must  either  be 
seated  or  standing.  If  he  is  recumbent,  in  the  dorsal  or 
ventral  position,  the  curve  disappears  on  account  of  the 
mobility  of  the  fluid  which,  by  gravitation,  flows  in  front 
or  in  back  through  the  length  of  the  costo-vertebral  space. 
This,  too,  is  remarkably  well  demonstrated  on  radioscopic 
examination. 

From  this  study  it  is  seen  that  the  curve  of  Damoiseau  is 
not  a  fixed  quantity.  It  is  a  kind  of  unstable  equilibrium 
between  the  fluid  and  the  lung  in  relation  alike  to  the  mo- 
bility of  the  fluid,  the  elasticity  and  fixity  of  the  lung  to- 
wards the  hilus.  It  is  an  essentially  transitory  phenomenon 
which  for  its  production  requires  a  definite  amount  of  fiuid, 
a  given  position  of  the  patient,  a  lung  free  from  adhesions 
and  a  pleural  cavity  without  any  form  of  obstruction.  In 
encysted  pleurisy  the  curve  of  Damoiseau  never  occurs.  In 
order  to  be  produced,  the  limit  of  the  effusion  would  have 
to  occur  in  a  particularly  fortunate  manner,  so  that  the 
curve  might  be  produced  completely. 

All  these  clinical  findings,  which  have  been  well  known 
but  poorly  accounted  for,  have  become  simple  and  easy  to 
understand,  owing  to  the  explanation  afforded  through 
radioscopic  examination. 

Study  of  the  diaphragm. — In  all  forms  of  pleurisy  of  the 
large  cavity,  there  is  absolute  immobilization  of  the  dia- 
phragm on  the  side  affected.  This  immobilization  is  rather 
difficult  to  determine  when  the  effusion  is  well  established 
and  when  it  obscures  almost  the  whole  of  the  thorax.  How- 
ever, on  the  left  side  it  is  relatively  easy.  The  presence  of 
the  gastric  air  bubble,  which  allows  the  inferior  side  of  the 
diaphragm  to  be  lighted  up,  shows  this  immobility.  When 
the  stomach  contains  no  gas,  it  can  be  introduced  artificially. 
It  is  entirely  different  on  the  right  side,  where  the  obscurity 
produced  by  the  liver  is  continued  without  any  line  of  de- 


PLEURISY  OF  THE  LARGE  CAVITY  21 

marcation  from  that  of  the  effusion.  But  if  the  diaphragm 
is  dijfficult  to  see  during  the  full  period  of  pleurisy,  it  is  quite 
otherwise  at  the  onset  and  the  retrogression  of  the  condi- 
tion. 

It  can  be  shown,  in  fact,  that  the  paralysis  of  the  dia- 
phragm precedes  the  effusion  and  that  it  survives  its  dis- 
appearance. In  one  case  Bar j  on  assisted  very  materially  in 
demonstrating  this  first  phenomenon.  A  patient  was  ad- 
mitted into  the  service  with  a  severe  stitch  in  the  side  which 
had  just  appeared  during  the  day.  He  was  radioscoped 
immediately  and  there  was  shown  on  the  diseased  side  a 
very  clear  hemithorax;  the  contour  of  the  diaphragm  and 
the  lateral  cul-de-sac  were  perfectly  intact  and  there  was 
no  trace  of  fluid  in  the  pleura.  But  the  diaphragm  was 
completely  immobilized  and  no  respiratory  movement  was 
seen,  while  on  the  opposite  side  it  was  very  extensive.  The 
next  day  another  examination  showed  that  the  effusion  was 
produced  in  the  interval  and  that  it  occupied  already  half 
of  the  hemithorax.  Immobilization  of  the  diaphragm, 
therefore,  precedes  effusion,  only  it  is  rarely  that  this  fact 
can  be  observed,  the  patients  ordinarily  being  seen  only 
when  effusion  is  established. 

On  the  other  hand,  the  diaphragm  during  the  period  of 
retrogression  of  the  effusion  may  constantly  be  observed, 
and  it  is  easy  to  see  that  its  paralysis,  or  better  still  its  im- 
mobilization, sometimes  persists  for  a  very  long  time  after 
complete  absorption  of  the  fluid.  This  point  will  be  taken 
up  later  in  connection  with  prognosis  and  the  end  results  of 
pleurisy. 

In  certain  cases  of  hydrothorax,  in  patients  with  Bright's 
disease,  the  movements  of  the  diaphragm  were  frequently 
retained  in  spite  of  the  existence  of  an  abundant  effusion. 
This  perhaps  may  have  an  interesting  significance  which 
might  permit  a  distinction  to  be  made  between  a  purely 
mechanical  effusion  (and  it  is  well  known  how  rare  they  are) 
and  those  which  are  accompanied  by  definite  pleural  in- 
flammation.   By  combining  clinical,  radiological  and  cyto- 


22  RADIO-DIAGNOSIS:  PLEUR.E 

logical  study  of  effusions  a  solution  of  this  interesting  ques- 
tion would  undoubtedly  be  reached. 

It  might  be  asked  whether  in  pleurisy  at  onset  there  really 
exists  a  true  paralysis  of  the  diaphragm,  and  whether  it  is 
not  rather  an  involuntary  immobilization  brought  about 
by  the  patient  due  to  the  painful  stitch  in  the  side  which 
the  respiratory  movements  exaggerate. 

Displacement  of  the  heart  and  mediastinum. — When  pleural 
effusion  is  sufficiently  large,  there  is  produced  a  char- 
acteristic deformation  of  the  radiological  image  of  the 
thorax.  Through  the  pressure  of  the  fluid,  the  median  parti- 
tition  of  the  thorax,  or  mediastinum,  which  is  most  movable, 
is  displaced  to  the  healthy  side,  including  the  heart  and 
other  organs  that  it  contains.  The  other  walls,  formed  by 
the  ribs,  firmly  attached  in  front  and  back,  offer  a  strong 
resistance.  All  movement  is  carried  on  by  the  diaphragm 
which  is  lowered  and  the  mediastinum  which  is  pushed  back. 
The  displacement  of  the  heart  and  of  the  mediastinum  is 
more  accentuated  the  more  considerable  the  effusion  is. 

The  determining  of  this  displacement  is  therefore  very 
important  from  many  points  of  view  and  nothing  is  easier 
than  to  show  it  by  radioscopic  examination.  It  is  seen  on 
the  screen  as  an  elongated  triangular  shadow,  bordering  on 
the  median  shadow.  Its  base  is  on  the  diaphragm  on  the 
opposite  side  and  its  apex  corresponds  to  the  sterno-clavicular 
articulation. 

The  presence  of  this  shadow  enlightens  and  confirms  diag- 
nosis. It  furnishes  valuable  indications  as  to  the  amount 
of  the  effusion  and  the  expediency  of  puncture.  It  helps  to 
explain  the  mechanism  of  the  displacement  of  the  heart, 
formerly  much  disputed. 

For  a  long  time  it  was  believed  that  the  displacement  of 
the  heart  took  place  as  a  turning  movement  on  its  own 
axis,  and  that  the  base  remaining  almost  immobile,  it  was 
the  apex  especially  which  was  displaced.  In  pleurisy  of  the 
left  side,  for  example,  it  was  believed  that  the  apex,  describ- 
ing a  large  arc  of  a  circle,  came  to  be  placed  under  the  right 


PLEURISY  OF  THE  LARGE  CAVITY  23 

breast.  The  pulsation  observed  at  this  level  was  erroneously 
attributed  to  the  apex. 

As  Bard  has  very  rightly  said,  everything  that  pulsates  is 
not  necessarily  the  apex;  and  this  author  has  had  the  dis- 
tinction of  showing  by  clinical  means  only  that  the  heart, 
instead  of  undergoing  such  a  twisting  movement,  was  simply 
pushed  back  ''en  masse,"  preserving  always  its  same  direc- 
tion. Radioscopic  examination  has  only  confirmed  the 
opinion  expressed  by  Bard.  It  is  easy,  by  following  the 
development  of  a  pleurisy  of  the  left  side,  to  verify  the  fact 
that  the  heart  is  pushed  over  ''en  masse"  and  that  the 
auricles  extend  over  to  the  right  of  the  median  line.  The 
auricles  are  recognizable  by  their  rounded  form  and  by  their 
pulsations.  As  for  the  apex,  it  tends  more  and  more  to  ap- 
proach the  shadow  of  the  sternum  until  it  is  obscured  behind 
it,  when  the  displacement  is  considerable. 

Development  and  Retrogression.  Modifications  after  Punc- 
ture. It  is  easy  to  follow  by  radioscopic  examination  the 
fluctuation  of  an  effusion  and  thus  to  verify  the  clinical 
findings. 

When  it  increases,  the  clear  superior  triangle  is  seen  to  be 
reduced  more  and  more  and  the  clearness  even  disappears 
completely;  the  hemithorax  is  then  entirely  obscure  from 
apex  to  base.  The  displacement  of  the  heart  and  mediasti- 
num is  accentuated  and  the  shadow  ultimately  covers  all 
but  a  third  of  the  pulmonary  field  on  the  healthy  side.  The 
effusion  is  then  considerable,  and  indications  are  for  an 
immediate  thoracentesis. 

When  the  fluid  retrogresses,  the  oblique  line  which  forms 
the  curve  of  Damoiseau  is  lowered  more  and  more  in  propor- 
tion as  the  clear  triangle  is  enlarged.  Soon  the  curve  disap- 
pears and  there  remains  only  a  diffuse  shadow  with  poorly 
defined  contour,  occupying  the  lower  third  of  the  pulmonary 
field.  At  this  time  the  displacement  of  the  heart  and 
mediastinum  has  disappeared  and  there  only  persists  a  com- 
plete obliteration  of  the  lateral  cul-de-sac,  with  immobiliza- 
tion of  the  diaphragm. 


24  RADIO-DIAGNOSIS:  PLEUR.^ 

In  large  effusion,  immediately  after  a  puncture,  even  if  as 
much  as  one  liter  of  fluid  has  been  withdrawn,  it  is  often 
astonishing  to  find  on  radioscopic  examination  no  modifica- 
tion of  the  image  of  the  thorax. 

The  obscurity  is  always  so  intense  and  so  extended  that 
it  appears  as  if  nothing  had  moved.  This  phenomenon 
may  be  explained  in  the  following  way:  when  a  certain 
quantity  of  fluid  has  been  withdrawn  from  the  thorax,  each 
of  the  walls  contracts  a  little  by  reason  of  its  natural  elasticity 
and  adapts  itself  to  the  new  volume  of  its  contents.  As  a 
result  of  this,  the  thoracic  convexity  diminishes,  the  ribs 
are  slightly  lowered,  the  diaphragm  is  elevated  a  little, 
pushed  up  by  the  abdominal  pressure,  and  the  mediastinal 
partition  approaches  the  median  line.  All  these  movements 
compensate  for  this  loss  of  fluid  and  the  level  of  the  fluid 
is  not  altered. 

This  equilibrium  is  only  temporary  and  during  the  follow- 
ing days  there  is  either  a  new  increase  or  a  definite  decrease 
of  the  pleurisy. 

Radiological  diagnosis. — As  has  already  been  said,  the  prin- 
cipal role  in  the  diagnosis  of  effusion  of  the  large  cavity 
belongs  to  the  clinician.  Most  often  diagnosis  is  simply 
confirmed  bj^  radioscopic  examination. 

However,  under  certain  circumstances,  radioscopy  plays 
a  more  important  part:  clinically  signs  are  present,  either 
without  the  existence  of  any  effusion;  or,  on  the  other  hand, 
an  effusion  is  present  without  stethoscopic  signs. 

Pseudo-effusions. — In  the  first  case,  it  is  pseudo- 
effusion.  The  patients  in  question  have  all  the  signs  of 
pleurisy  of  the  large  cavity:  dullness,  fremitus,  abnormal 
breathing,  egophony  and  aphonic  pectoriloquy;  and  yet 
there  is  no  pleural  effusion. 

This  phenomenon  may  be  present  under  many  circum- 
stances and  radioscopic  examination  has  here  a  great  value. 
It  demonstrates,  in  fact,  that  in  spite  of  these  deceptive 
symptoms,  the  pleura  is  free  of  fluid,  the  hemithorax  is 
perfectly  clear  from  apex  to  base,  the  diaphragmatic  dome 


PLEURISY  OF  THE  LARGE  CAVITY  25 

stands  out  clearly,  and  if  the  respiratory  movements  are 
weak  and  lessened  in  extent,  the  diaphragm  is  not  com- 
pletely immobilized.  It  is  certain,  therefore,  that  there  is 
no  effusion. 

This  negative  diagnosis  ought  to  suggest  a  positive  diag- 
nosis if  we  take  into  consideration  all  the  indications  fur- 
nished by  the  history,  clinical  examination,  the  development 
of  the  disease,  and  radioscopic  examination. 

Grancher  described  some  years  ago,  under  the  name  of 
'^spleno-pneumonie"  a  clinical  syndrome  which,  under  the 
appearance  of  pleurisy,  is  not  accompanied  by  any  effusion. 
It  is  a  particular  condition  of  the  lung  in  which  consequently 
thoracic  symptoms  always  ought  to  predominate.  It  is 
produced  in  bronchitis,  pulmonary  congestions,  pneumonias. 
It  may  be  a  form  of  incipient  tuberculosis.  Finally,  it  is 
met  with  in  the  course  of  general  infectious  diseases,  such 
as  rheumatism  and  typhoid  fever. 

If  in  such  a  case  radioscopic  examination  shows  that  there 
is  no  effusion,  it  can  also  bring  out  abnormal  pulmonary 
shadows  which  may  serve  to  confirm  the  diagnosis  of  spleno- 
pneumonia.  But  there  may  be  met  with,  outside  of  this 
condition,  clinical  signs  of  pseudo-effusion. 

Barjon  drew  attention  some  time  ago  (Lyon  Med.,  1912, 
Vol.  I,  p.  908)  to  two  cases  of  subdiaphragmatic  affections 
producing  this  complete  syndrome  without  there  being,  how- 
ever, any  fluid  in  the  pleura.  One  of  these  patients  had 
an  abscess  of  the  liver,  the  other,  suppurated  cyst  of  the 
same  organ.  Similar  facts  have  been  observed  in  certain 
cases  of  subphrenic  abscess. 

In  these  conditions  radioscopic  examination  shows  the 
persistence  of  thoracic  clearness  as  far  as  the  base.  The 
contour  of  the  diaphragm  has  retained  all  its  clearness,  but 
it  is  raised  higher  into  the  thoracic  cavity  with  reference  to 
the  opposite  side;  its  respiratory  movements  are  much  de- 
creased or  abolished;  and  all  these  signs  attract  attention 
away  from  the  subdiaphragmatic  region. 

It  is  in  these  cases  of  pseudo-effusion  that  radioscopic 


26  RADIO-DIAGNOSIS:  PLEURA 

examination  is  most  useful,  because  it  enables  us  to  make 
sure  that  there  is  no  fluid  in  the  pleura. 

Inversely,  when  a  pleural  effusion  exists  which  does  not 
give  any  stethoscopic  signs,  or  only  pulmonary  signs,  the 
findings  furnished  by  radioscopic  examination  may  still  be 
very  useful,  but  they  have  not  as  absolute  a  value  and  their 
interpretation  is  a  matter  of -more  care.  This  may  be  pro- 
duced under  three  conditions:  either  with  a  large  total 
effusion,  or  with  an  extended  effusion  associated  with  pul- 
monary lesions,  or,  on  the  contrary,  with  a  small  amount 
of  fluid. 

Large  total  effusion. — When  the  effusion  is  total,  the  clin- 
ical signs  may  be  confined  to  dullness  with  absence  of  fre- 
mitus. On  account  of  the  compression  of  the  lung,  no 
abnormal  breathing,  egophony,  or  aphonic  pectoriloquy  is 
heard.  The  radioscopic  image  shows  total  obscurity  of  the 
whole  hemithorax;  no  clearness  remains  at  any  point, 
neither  the  line  of  level,  nor  the  characteristic  curve;  but 
uniform  opacity  throughout. 

The  screen  shows  only  one  thing,  but  to  this  a  certain 
amount  of  importance  ought  to  be  attached;  namely,  the 
displacement  of  the  heart  and  mediastinum,  which  ordinarily 
is  considerable.  This  sign  alone  ought  to  direct  diagnosis 
which  probably  can  be  confirmed  by  exploratory  puncture. 

It  is  exceptional  for  a  cyst  or  a  tumor,  even  if  large  enough 
to  cause  a  displacement  of  the  mediastinum,  to  be  able  to 
obliterate  entirely  the  clearness  of  the  pulmonary  field 
throughout  the  hemithorax.  Barjon  has  never  observed  it. 
A  small  clear  zone  at  the  apex  or  at  the  base  always  persists, 
limited  by  a  curve  which  generally  takes  a  direction  exactly 
inverse  to  that  of  pleurisy.  This  detail  alone  ought  to  be 
sufficient  to  attract  attention. 

Association  of  pulmonary  lesions. — The  effusion  may  be  of 
medium  amount  but  associated  with  more  or  less  extensive 
pulmonary  lesions,  which  modify  considerably  the  steth- 
oscopic signs  and  the  radioscopic  image. 

These  conditions  may  occur  in  certain  cases  of  tuberculosis. 


PLEURISY  OF  THE  LARGE  CAVITY  27 

but  it  is  especially  during  the  course  of  pneumonia  that  the 
difficulties  of  diagnosis  are  most  often  encountered. 

Sometimes  pneumonia  occurs  in  which  recovery  is  not 
normal.  Sometimes  resolution  does  not  take  place;  some- 
times after  a  transitory  defervescence  the  temperature  rises 
again  and  the  general  symptoms  are  aggravated.  The  ques- 
tion is  whether  it  is  pneumonia  with  slow  resolution,  a  new 
pneumonic  attack,  or  a  pneumonic  pleurisy,  either  inter- 
lobar or  of  the  large  cavity,  which  may  require  intervention. 
The  clinician  is  often  unable  to  state  this  positively. 

Auscultation  may  reveal  miscellaneous  pleural  and  pul- 
monary signs  difficult  to  interpret.  The  dullness  persists, 
fremitus  is  scarcely  perceptible,  the  breathing  is  more  bron- 
chial than  pleuritic,  loose  rales  of  all  kinds  are  sometimes 
heard  as  far  as  the  base;  it  is  impossible  to  affirm  the  exist- 
ence of  effusion. 

The  question  of  interlobar  pleurisy  will  be  taken  up  later 
on. 

If  the  base  is  clear  and  the  contour  of  the  diaphragm  is 
retained,  while  a  shadow,  or  shadows,  occupy  the  upper  part 
of  the  lung,  it  may  be  affirmed  that  the  large  pleural  cavity 
is  not  involved.  But  if  the  base  is  obscure,  interpretation 
becomes  more  difficult. 

There  may  be  a  total  obscurity  from  apex  to  base  either 
when  there  is  present  massive  pneumonia,  a  superposition 
of  an  effusion  of  the  base  and  an  hepatization  of  the  apex, 
or  when  there  exists  a  solid  lung  in  the  fluid  which  causes  the 
slight  effusion  to  rise  as  far  as  the  apex. 

In  such  a  case,  displacement  of  the  heart  and  mediastinum 
cannot  even  be  demonstrated  as  it  often  does  not  exist  on 
account  of  the  small  amount  of  fluid.  Radioscopy  is,  there- 
fore, unable  to  solve  the  question.  It  is  necessary  to  be 
careful  and  to  guard  against  too  positive  statements. 

Very  few  pulmonary  processes  are  capable  of  producing 
total  and  uniform  obscurity  of  the  hemithorax  and  always  in 
these  cases  the  existence  of  a  pleural  effusion  should  be  sus- 
pected.   But  if  its  existence  after  radiological  examination 


28  RADIO-DIAGNOSIS:  PLEURA 

alone  cannot  be  affirmed,  it  will  be  necessary  to  rely  on  the 
findings  of  this  examination  sufficiently  to  demand  one  or 
more  exploratory  punctures. 

Slight  effusio?is  or  effusions  in  retrogression. — The  same 
difficulties  are  met  with  here.  Very  often  it  is  impossible 
to  say  whether  fluid  still  remains  in  the  pleura.  The  radio- 
scope  shows  a  diffuse  shadow  of  the  base,  always  more  ex- 
tensive outward  than  inward,  without  exact  outline.  The 
diaphragm  is  always  immobilized,  but  displacement  of  the 
heart  or  mediastinum  is  no  longer  seen. 

This  shadow  may  depend  on  the  persistence  of  a  small 
quantity  of  fluid,  but  it  may  remain  long  after  its  absorption. 
It  is  due  to  the  presence  of  exudates  not  yet  absorbed,  to 
the  persistence  of  atelectasis  of  the  lung  which  has  been  com- 
pressed for  a  long  time  towards  the  base,  and  to  paralysis 
of  the  diaphragm.  Radioscopy  is  therefore  not  able  to  give 
information  on  this  point  and  besides  at  this  stage  it  is  of  no 
great  interest. 

Difficulty  of  Diagnosis  in  Children. — It  is  often 
difficult  to  affirm  the  presence  of  pleural  effusion  in  children 
by  radioscopic  examination  alone.  Because  of  the  smallness 
of  the  thorax  the  obscurity  is  never  as  important  as  in  the 
adult  and  in  spite  of  the  use  of  medium  penetrating  rays  the 
entire  costal  grill  continues  to  be  perceptible.  Besides,  the 
elasticity  and  mobility  of  the  ribs  allows  much  more  margin 
to  the  effusion  and  as  a  result  the  displacement  of  the  heart 
and  of  the  mediastinum  is  much  less  pronounced  in  them 
than  it  is  in  the  adult.  These  modifications  of  the  radio- 
scopic image  ought  not  to  cause  the  diagnosis  of  an  effusion 
to  be  dismissed,  but  caution  should  be  used. 

Diagnosis  of  the  Type  of  Pleurisy. — This  diagnosis 
ought  to  be  exclusively  clinical.  Radioscopy  might,  if  nec- 
essary, furnish  some  information  as  to  the  existence  of  other 
concomitant  thoracic  lesions  which  have  a  more  or  less  active 
part  in  the  formation  of  an  effusion ;  for  example,  pulmonary 
lesions,  a  tumor  of  the  hmgs  or  mediastinum,  an  aneurysm  of 
the  aorta.    But  it  can  give  no  indication  of  the  serofibrinous, 


PLEURISY  OF  THE  LARGE  CAVITY  29 

purulent  or  hemorrhagic  condition  of  the  fluid.  Formerly 
it  was  thought  possible  to  distinguish  radioscopically  be- 
tween purulent  and  serofibrinous  efl'usions;  it  was  claimed 
that  the  purulent  effusions  were  less  opaque  than  the  others. 
This  distinction  has  been  found  inaccurate,  and  only  the 
findings  drawn  from  the  topography  and  the  extent  of  the 
shadows  can  be  taken  into  consideration.  That  is  to  say 
that,  except  in  the  case  of  interlobar  pleurisy,  where  the 
probabilities  are  in  favor  of  purulence,  radioscopic  examina- 
tion furnishes  no  exact  findings  to  establish  this  diagnosis. 

Radiological  Prognosis  of  Pleurisy:  its  after  Ef- 
fects.— When  a  pleurisy  is  systematically  examined  in 
process  of  resolution,  either  by  spontaneous  retrogression,  or 
after  thoracentesis,  a  series  of  modifications  is  observed 
which  from  their  appearance  and  their  more  or  less  rapid 
progress  furnish  interesting  elements  of  prognosis.  It  is 
the  same  after  empyema  operations  in  the  course  of  a  pu- 
rulent pleurisy. 

After  a  serofibrinous  pleurisy  the  pulmonary  functions 
may  be  seen  to  be  rapidly  re-established  in  favorable  cases. 
From  the  time  that  the  fluid  is  absorbed,  the  base  of  the 
hemithorax  becomes  visible  again;  the  contour  of  the  di- 
aphragm reappears,  the  respiratory  movements  are  re- 
established. The  extent  of  the  respiratory  movement  be- 
comes very  quickly  equal  to  that  of  the  other  side,  the  lateral 
cul-de-sac  resumes  its  original  form,  and  in  a  few  weeks  it  is 
impossible  to  find  by  radioscopic  examination  the  least 
indication  as  to  the  side  on  which  the  effusion  was  produced. 
This  happens  in  the  most  favorable  types  and  it  must  be 
recognized  that  it  is  rather  rare. 

In  other  cases,  the  development  is  less  rapid  but  the 
prognosis  remains  nevertheless  favorable.  The  obscurity 
of  the  base  and  the  immobilization  of  the  diaphragm  per- 
sist for  several  weeks  or  months;  then  gradually  the  respir- 
atory functions  are  re-established  and  no  further  trace  of  the 
old  lesion  remains. 

Certain  pleurisies,  on  the  contrary,  leave  indelible  marks. 


30  RADIO-DIAGNOSIS:  PLEUR.E 

Adhesions  persist  between  the  two  folds  of  the  pleura,  ending 
in  partial  or  total  sjanphysis.  This  results  in  retraction  of 
the  thorax  with  lowering  of  the  ribs,  narrowing  of  the  inter- 
costal spaces  and  inclination  of  the  costo-\'ertebral  angle. 
The  diaphragm  remains  adherent  to  the  base  of  the  lung, 
the  respiratory  movements  never  regain  their  mobility  and 
the  pulmonary  functions  are  never  entirely  re-established. 
The  heart  is  often  displaced  in  the  movement  of  retraction 
of  the  thorax,  bound  by  adhesions  and  fixed  in  an  abnormal 
position  (dextrocardia  or  sinistrocardia).  In  these  patients 
retrospective  diagnosis  of  an  old  pleurisy  can  be  made  by 
radiological  examination  several  years  later. 

The  rapidity  with  which  the  pulmonary  functions  are  re- 
established during  the  first  few  days  after  a  pleurisy  permits 
one  to  determine  in  advance  to  which  type  it  belongs. 

In  purulent  pleurisy,  after  empyema  operation,  but  only 
in  the  first  days  following  intervention,  Destot  and  Violet 
have  shown  the  signs  on  which  prognosis  should  be  based. 
The  deduction  is  made  from  examination  of  the  pulmonary 
permeability  and  expansion. 

Pulmonary  permeability  is  estimated  by  the  degree  of 
clearness  of  the  lung  during  respiration.  Expansion  is  the 
functional  tendency  of  the  lung  to  fill  the  pleural  cavity. 

Prognosis  is  favorable  if  the  permeability  and  expansion 
are  satisfactory.  Spontaneous  recovery  ought  to  be  ex- 
pected. 

Prognosis  is  less  favorable  if  permeability  remains  normal 
and  expansion  is  lacking.  In  this  case  spontaneous  re- 
covery cannot  be  expected  until  the  obstacle  to  expan- 
sion is  removed;  that  is  to  say,  until  decortication  is 
resorted  to. 

Finally,  prognosis  is  distinctly  unfavorable  if  the  per- 
meability and  expansion  are  both  lacking.  In  this  case,  de- 
cortication becomes  altogether  insufficient  and  the  cavity  can 
be  filled  only  by  the  breaking  down  of  the  wall.  Resection 
of  the  ribs  must  then  be  done. 

Radioscopic  examination  would  be  able  in  this  case  to 


PLEURISY  OF  THE  LARGE  CAVITY  31 

indicate  at  the  same  time  the  prognosis  and  the  method  of 
intervention. 

Dry  Pleurisy. — The  radiological  study  of  dry  pleurisy 
is  much  less  important  than  that  of  pleurisy  with  effusion. 

In  partial  dry  pleurisy  there  are  small,  local,  well  defined 
lesions  of  irregular  surface,  fibrinous  deposits,  thickening  of 
the  folds  (of  the  pleura)  and  adhesions.  These  lesions  are 
usually  caused  by  underlying  pulmonary  lesions,  and  in  the 
abnormal  shadow  resulting  it  is  impossible  to  determine  radio- 
scopically  what  belongs  to  the  pleura  and  what  to  th^  lungs. 

Auscultation,  when  it  discloses  the  presence  of  friction  or 
a  diminution  of  pulmonary  expansion,  recognizes  dry  pleu- 
risy. Most  frequently  these  lesions  can  only  be  suspected 
and  their  existence  can  be  inferred  only  after  the  demonstra- 
tion of  superficial  pulmonary  foci,  because  it  is  known  that 
these  lesions  are  usually  accompanied  by  local  pleural  reac- 
tions, especially  in  the  tuberculous. 

Total  or  very  extensive  dry  pleurisy  is  seen  after  pleurisy 
or  during  the  course  of  some  chronic  extensive  pulmonary 
affection,  such  as  slowly  progressing  tuberculosis.  It  is 
then  seen  as  partial  or  total  sjnuphysis.  Nothing  is  more 
difficult  than  the  clinical  diagnosis  of  these  symphyses. 

Radioscopic  examination  often  gives  valuable  indications 
for  detecting  them.  In  recent  cases  it  shows  a  relative  obscu- 
rity of  the  base.  The  diaphragmatic  contour  has  lost  its 
clearness  and  is  often  deformed.  Its  mobility  is  reduced  to 
a  large  extent;  sometimes  even  the  respiratory  movements 
are  completely  suppressed.  The  costodiaphragmatic  sinus 
is  reduced  in  breadth  and  depth,  is  half  filled,  even  sometimes 
totally  effaced. 

In  older  cases  a  certain  deformity  of  the  thorax  is  found  in 
addition.  There  exists  a  retraction  of  the  hemithorax  with 
a  narrowing  of  the  pulmonary  field.  The  ribs  deviate, 
incline  towards  the  vertebral  column,  and  approach  one 
another  as  if  to  efface  the  intercostal  spaces.  The  heart  may 
be  involved  in  this  movement  of  general  retraction,  displaced 
and  fixed  in  dextro  or  sinistrocardia. 


32  RADIO-DIAGNOSIS:  PLEUR.^ 

Unfortunately  these  radioscopic  symptoms  are  not  con- 
stant and  there  may  exist  symphyses  which  nothing  has 
revealed.  The  following  observation  is  interesting  from  this 
point  of  view :  A  tuberculous  patient  with  advanced  bilateral 
lesions  presented  the  following  radioscopic  appearance:  very 
extensive  diffuse  obscurity  of  the  left  side,  occupying  the 
upper  two-thirds  of  the  lung;  an  elongated  gray  shadow  ex- 
tending to  the  diaphragm;  immobilization  of  the  diaphragm 
and  eff acement  of  the  costodiaphragmatic  sinus ;  at  the  right, 
a  less  extensive  obscurity  occupying  only  the  upper  part  of 
the  lung.  Contour  of  the  diaphragm  and  sinus  normal. 
Respiratory  movements  were  retained  with  a  rather  large 
amplitude.  In  this  patient  pleural  symphysis  of  the  left 
side  was  thought  of;  on  the  right,  it  was  supposed  only  some 
adhesions  existed  in  the  upper  part  of  the  chest,  the  site  of 
old  lesions.  Autopsy  showed  a  total  double  symphysis,  very 
adherent  on  both  sides  and  it  was  necessary  to  dissect  the 
lung  in  order  to  separate  it  from  the  diaphragm. 

The  only  difference  was  in  the  extent  of  the  pulmonary 
lesions.  On  the  left  these  lesions  were  enormous;  all  the 
upper  lobe  was  infiltrated,  softened,  pitted  with  small  cav- 
ities; the  lower  lobe  was  full  of  tuberculous  bronchopneu- 
monic  foci,  almost  confluent,  many  of  which  were  already 
softened  in  the  center.  On  the  right,  there  were  found  ex- 
tensive lesions  in  the  upper  lobe;  the  middle  lobe  was  almost 
intact;  and  the  lower  lobe  contained  only  some  undiscov- 
ered, very  small  patches  of  tuberculous  bronchopneumonia. 
Finally,  the  left  lung  was  reduced  to  zero  from  a  respiratory 
point  of  view,  while  the  right  was  to  a  great  extent  still  per- 
meable to  air. 

It  is  to  this  cause  that  the  difference  in  radioscopic  appear- 
ance ought  to  be  attributed  and  not  to  the  symphysis,  which 
was  equal  on  both  sides. 

The  symphysis  immobilized  the  left  lung  which  no  longer 
functioned.  The  pulmonary  portion  which  filled  the  sinus 
had  become  opaque  owing  to  the  tuberculous  lesions  and 
the  resulting  impermeability.     The  diaphragm  had  become 


PLEURISY  OF  THE  LARGE  CAVITY  33 

immobile  since  the  lung  had  lost  all  elasticity  and  respiratory 
function. 

On  the  right  the  lung  still  functioned  to  a  very  appreciable 
degree;  the  portion  of  the  lung  which  filled  the  sinus  had 
remained  clear  and  the  movements  of  the  diaphragm  were 
still  quite  extensive. 

This  shows  that  symphysis  is  not  everything;  that  it  is 
not  always  sufficient  in  itself  to  immobilize  the  diaphragm 
and  that  the  lung  plays  a  very  important  role  in  the  mech- 
anism of  the  respiratory  movements.  It  is  the  stimulus  of 
these  movements  and  starts  the  respiratory  reflex.  While 
the  lung  is  able  to  do  this,  adhesions,  even  when  very  adher- 
ent, are  not  enough  completely  to  immobilize  the  diaphragm. 

This  shows,  besides,  that  there  may  exist  a  total  symphysis 
without  its  being  manifest  on  the  radioscopic  screen  by  any 
apparent  symptom.  Inversely,  an  extensive  purely  pulmo- 
nary process  is  sufficient  to  obscure  the  base,  to  efface  the 
sinus,  to  diminish  the  amplitude  of  the  respiratory  move- 
ments to  the  point  of  immobilization — all  this  without  there 
being  any  adhesion. 


CHAPTER  II 
CIRCUMSCRIBED  AND  ENCYSTED  PLEURISY 

PLEURISY^  may  be  circumscribed  in  a  portion  of  the 
pleura  only,  and  serofibrinous  purulent  effusions  may 
form  and  become  encysted  in  a  defined  area  of  the  pleural 
sac  without  communicating  with  the  large  cavity.  This 
cyst  may  form  in  any  portion  of  the  pleura.  Andral  has 
described  an  encysted  pleurisy  of  the  apex,  and  more  re- 
cently Agasse-Lafont  has  reported  another  case  of  localiza- 
tion in  the  right  apex  (Soc.  med.  des  Hop.,  1910).  But  there 
exist,  however,  some  points  of  predilection  for  this  process. 
The  pleurisy  then  takes  the  name  of  the  region  where  it  is 
encysted.  There  is,  therefore,  in  the  order  of  its  importance: 
interlobar,  diaphragmatic  and  mediastinal  pleurisy.  Pleu- 
risy of  the  region  of  the  hilus  will  be  also  mentioned.  Some- 
times these  forms  remain  separate;  sometimes  they  are  com- 
bined. Complex  forms  are  then  produced  such  as  pleurisy 
*'en  ^querre"  of  ChaufTard,  made  up  of  a  combination  of  the 
diaphragmatic  and  mediastinal  forms. 

The  radiological  study  of  encysted  pleurisy  is  extremely 
interesting.  Clinical  diagnosis  is  hard  to  establish.  Radio- 
scopic  examination  therefore  becomes  of  the  greatest  use  in 
detecting  slight  effusions,  but  is  not  limited  to  that  alone. 
Pleurisy  most  often  is  purulent  and  necessitates  intervention. 
It  is  not  sufficient  to  determine  its  presence,  but  it  is  also 
necessary  to  ascertain  exactly  its  location  and  indicate  from 
what  point  it  should  be  approached. 

Interlobar  Pleurisy. — Among  the  encysted  pleurisies, 
interlobar  pleurisy  is  one  of  the  most  important,  as  much 
from  its  frequency  as  from  the  difficulty  of  diagnosis.  The 
lesion,  located  in  one  of  the  interlobar  spaces,  is  deeply  sit- 
uated and  consequently  difficult  of  access  by  the  usual  means 

34 


Radiograph  1.  PLEURISY  OF  THE  LARGE  CAVITY  WITH  MARKED 
EFFUSION.  CONDITION  COMPLETE 
Pleurisy  on  right.  Abundant  fluid  in  the  large  cavity.  Obscurity  is  uniform  and 
complete  of  the  lower  two-thirds  of  the  right  hemithorax.  Superior  triangle  clear. 
Light  zone  between  the  dark  part  and  the  light  part;  oblique  direction  of  this  line 
of  separation  above  and  below  and  from  without  inward.  Marked  deviation  of 
the  heart  and  mediastinum  to  the  left. 


Radiograph  2.     TUBERCULOUS  PLEURISY  OF  THE  LARGE  CAVITY  ON 
THE  RIGHT.     PERIOD  OF  REGRESSION,  DIMINUTION  OF  FLUID 
Tuberculous  pleurisy  of  the  large  cavity  on  the  right,  progressive   regression. 

There  is  not  much  fluid  elsewhere.     Persistence  of  obscuritj'  at  the  right  base  due 

to  the  presence  of  exudates  and  a  pulmonary  atelectasis. 

The  convexitj-  of  the  diaphragm  is  not  seen,  nor  the  costo-diaphragmatic  sinus. 

The  respiratory  movement  is  completely  abolished.     Enlargement   of  the  hilus 

shadow  on  the  right  (tuberculous  glands  of  hilus) .      Discrete,  disseminated  shadows 

in  the  upper  part  of  both  lungs.     Pulmonary  lesions. 


CIRCUMSCRIBED  AND  ENCYSTED  PLEURISY     35 

of  exploration.  In  1899  Guinon  insisted  on  the  difficulty  of 
diagnosis  of  this  type  of  pleurisy.  Radioscopic  examination 
is  therefore  indicated  in  these  cases. 

Interlobar  pleurisy,  like  that  of  the  large  cavity,  may  be 
dry  or  accompanied  by  effusion. 

Interlobar  pleurisy  with  effusion. — This  is  the  most  inter- 
esting form  because  it  admits  of  surgical  treatment  and  the 
radioscopic  examination  is  almost  indispensable  in  deter- 
mining the  indications  for  it.  The  effusion  is,  in  fact,  almost 
always  purulent  and  must  be  evacuated. 

In  exceptional  cases  this  effusion  may  be  serous.  Gerhardt 
published  a  case  in  1907,  where  absorption  was  spontaneous. 


Fig.  7.     INTERLOBAR  PLEURISY 

Diagnosis  was  made  by  radioscopic  examination  and  the 
progressive  diminution  of  the  effusion  up  to  its  complete 
disappearance  could  be  followed  on  the  screen.  Similar 
findings  have  been  reported  by  Sabourin  (Rev.  de  Aled., 
1909)  in  tuberculous  patients. 

Whatever  the  nature  of  the  effusion,  the  radioscopic  image 
remains  the  same  and  it  is  especially  important  to  recognize 
this  in  order  not  to  overlook  the  diagnosis. 

The  radioscopic  image  is  quite  characteristic.  It  consists 
of  a  transverse  opaque  band  which  entirely  crosses  the  clear 
pulmonary  field.     The  lung  is  therefore  divided  into  three 


36  RADIO-DIAGNOSIS:  PLEURA 

zones:  a  dark  zone  between  two  clear  zones — one  above  it, 
the  other  below  it.  This  image  is  superimposed  on  what  has 
been  clinically  termed  ''matite  suspendue"  and  considered 
a  characteristic  sign  of  this  affection. 

The  dmiensions  of  these  three  zones  are  variable  according 
to  the  case,  and  especially  variable  on  the  right  where  two 
mterlobes  exist.  The  distance  between  the  two  interlobes 
being  slight,  sometimes  no  unportant  modification  occurs 
in  the  topography  of  the  radioscopic  image.  The  respiratory 
movements  of  the  diaphragm  are  usually  retained. 

The  intermediary  opaque  band  shows  as  well  outlines  of 
variable  form.  Sometimes  it  is  defined  by  two  almost 
horizontal  lines;  sometimes  one  of  these  lines  curves  under 
the  pressure  of  the  fluid  and  the  outline  of  the  shadow  be- 
comes convex  either  above  or  below. 

Finally,  if  the  effusion  still  increases  and  the  tension  ex- 
tends to  the  interior  of  the  sac,  a  convexity  of  both  sides  forms 
and  the  image  takes  on  an  irregularly  oval  or  rounded  form. 
This  appearance  may  suggest  a  cyst,  but  the  contour  is 
never  as  regularly  spherical  and  the  clinical  development 
is  quite  different. 

The  remaining  characteristic  of  interlobar  pleurisy  is  the 
existence  of  a  continuous  transverse  opaque  band,  cutting 
from  one  side  to  the  other  the  clear  pulmonary  field  without 
any  break  in  continuity.  This  is  what  distinguishes  it 
radioscopically  from  an  abscess  of  the  lung,  the  location  of 
which  is  quite  different.  The  shadow  of  the  abscess  never 
goes  from  one  side  to  the  other;  it  never  obstructs  the  thorax, 
and  is  surrounded  either  totally  or  at  least  on  two  or  three 
sides  by  a  clear  zone. 

However,  at  the  very  onset,  during  the  formation  of  inter- 
lobar pleurisy  (as  observed  by  Bar j  on  in  one  case)  the  image 
may  not  be  complete  at  first.  The  shadow  may  be  localized 
at  one  end  of  the  interlobe  or  at  the  side  of  the  hilus,  for  that 
is  where  infection  usually  takes  place.  Radiological  diagno- 
sis is  almost  impossible  at  this  time  as  glands  of  the  hilus  or 
a  tumor  must  be  considered.     In  a  few  days,  however  (15 


CIRCUMSCRIBED  AND  ENCYSTED  PLEURISY     37 

days  in  Barjon's  case),  the  image  becomes  complete;  the  in- 
terlobe  is  affected  in  its  entirety  and  the  characteristic  band 
obstructing  the  hemithorax  throughout  its  width  appears. 

The  diagnosis  of  interlobar  pleurisy  is  relatively  easy  when 
the  image  is  complete.  Radioscopic  examination  is  indis- 
pensable in  confirming  it.  In  many  cases  clinical  errors  will 
be  avoided,  for  in  such  patients  this  is  often  mistaken  for 
tuberculosis  or  pneumonia  progressing  towards  suppuration, 
in  which  prognosis  is  much  more  serious.  The  formation  of 
pus  may  be  anticipated,  or  better  still,  indication  for  surgical 
intervention  established. 

This  indication  having  been  established,  radioscopic 
examination  determines  accurately  the  point  of  entrance  for 
intervention.  It  is  easy,  in  fact,  by  means  of  rays  of  normal 
incidence  to  draw  on  the  skin  the  exact  contours  and  the 
definite  outlines  of  the  purulent  collection  in  order  to  in- 
dicate to  the  surgeon  at  what  intercostal  spaces  it  ought  to 
be  approached. 

This  intervention  is  the  most  favorable  solution  and  that 
is  why  its  exact  indication  is  so  important.  In  fact,  evacua- 
tion by  vomica  is  very  often  insufficient  and  under  these 
conditions  suppuration  remains  a  long  time  and  with  it 
cough,  fever  and  purulent  expectoration. 

False  recovery  through  vomica. — Radioscopic  examination 
is  even  very  useful  after  the  evacuation.  Diagnosis  which 
Was  only  suspected  through  evacuation  may  be  confirmed 
when  examination  is  made  during  the  days  immediately 
following;  progress  of  recovery  may  be  followed  and  the 
cavity  may  be  gradually  seen  to  fill  up.  Finally,  the  ex- 
istence of  an  old  interlobar  pleurisy  may  be  recognized  and 
a  diagnosis  corrected  which  was  misleading  because  of  lack 
of  knowledge  of  the  former  facts  of  the  case. 

After  evacuation,  the  radioscopic  image  of  interlobar 
pleurisy  appears  as  a  partial  pyopneumothorax.  In  the 
lower  part  of  the  cavity  a  small  quantity  of  pus  remains 
which  could  not  be  evacuated  and  gives  a  rather  limited 
opaque  shadow,  while  above  this  there  exists  a  clear  zone 


38  RADIO-DIAGNOSIS:  PLEUR.E 

filled  with  air  which  entered  at  the  time  of  evacuation  and 
which  is  constantly  renewed  through  the  bronchial  fistula. 
These  two  zones — clear  and  opaque — are  limited  by  a  hori- 
zontal and  mobile  line  which  recalls  exactly  the  image  of 
pyopneumothorax  of  the  large  cavity.  It  differs  from  it  in 
its  smaller  dimensions  and  its  higher  position. 

Sometimes,  following  a  more  complete  evacuation,  the 
cavity  may  be  entirely  emptied  and  the  line  of  level  dis- 
appears in  the  course  of  a  few  hours.  At  this  time  only  a 
clear  cavity  is  seen,  surrounded  by  a  more  opaque  zone,  due 
to  the  thickening  of  the  layers  of  the  pleura,  which  resembles 
to  a  certain  degree  the  image  of  a  pulmonary  cavity.  But 
presently  a  new  purulent  secretion  is  produced  and  the  line 
of  level  reappears. 

Sergent  has  already  rightly  insisted  on  pseudo  cures  of 
interlobar  pleurisy  by  evacuation.  He  has  shown  cases  of 
suppuration  persisting  for  several  months.  Barjon  has  had 
occasion  to  observe  a  still  older  case  in  which  radioscopic 
examination  was  of  the  greatest  service. 

It  was  a  man  about  fortj'^-five  years  old,  of  tuberculous 
appearance,  who  entered  the  hospital  during  Barjon's  service. 
Seventeen  years  previously  he  had  had  pleurisy,  concerning 
the  nature  of  which  he  gave  no  information.  Since  then 
he  had  had  a  continual  cough  and  expectoration  which  was 
purulent,  often  with  hemoptysis.  He  had  grown  thin  and 
had  a  slight  temperature.  Upon  examination  dullness  was 
noted  over  almost  the  whole  of  the  left  lung  and  auscultation 
revealed  the  presence  of  rather  numerous  moist  rales  with 
a  marked  decrease  of  the  vesicular  sound.  The  right  lung 
appeared  sound.  Clinically  very  little  was  indicated  except 
pulmonary  tuberculosis. 

Radioscopic  examination  showed  the  existence  of  a  slight 
partial  pyopneumothorax.  The  tuberculous  serodiagnosis 
was  negative;  the  sputum  contained  no  Koch  bacilli.  On 
questioning  the  patient  carefully,  the  existence  of  a  previous 
evacuation  was  discovered,  dating  back  seventeen  years. 
In  spite  of  the  length  of  time  since  this  manifestation,  a 


Radiograph  3.  OLD  PURULENT  PLEURISY  OF  THE  LARGE  CAVITY. 
EMPYEMA.  PERSISTENCE  OF  A  THORACIC  FISTULA  WITH  PNEU- 
MOTHORAX 

Marked  clearness  of  the  inferior  external  portion  of  the  right  hemithorax.  Pneu- 
mothorax, suppuration  drained  by  the  thoracic  fistula,  no  retention.  Lung  ad- 
herent and  sclerous.  Sclerous  lines  in  the  entire  upper  part  of  both  lungs,  especially 
on  the  right. 

Displacement  of  heart  and  mediastinum  to  the  left,  held  by  adhesions. 

Intervention — Large  costal  resection,  drainage  of  the  cavity.    Recovery. 


Radiograph  4.    OLD  INTERLOBAR  PLEURISY  ON  THE  LEFT  OF  17  YEARS' 

STANDING.      PERSISTENCE    OF    PARTIAL    PYOPNEUMOTHORAX 

WITH  BRONCHIAL  FISTULA 

Obscurity  of  almost  the  entire  left  hemithorax  with  a  clear  oblong  portion  in  the 

superior  external  region.     Partial  pyopneumothorax.     Retraction  and  deformation 

of  the  thorax,  narrowing,  sloping  and  drawing  together  of  the  ribs.     Scoliosis  due 

to  an  old  suppurated  interlobar  pleurisy  incompletely  emptied  by  vomica. 

Intervention — Incision,  resection  of  3  ribs,  drainage  of  the  cavity.    Recovery. 


CIRCUMSCRIBED  AND  ENCYSTED  PLEURISY     39 

diagnosis  of  old  interlobar  pleurisy  was  made.  This  diag- 
nosis was  confirmed  by  the  physician  who  had  attended  him 
at  that  time.  Since  then  the  bronchial  fistula  had  never 
closed;  the  patient  had  slight  evacuations  from  time  to  time 
and  suppuration  had  persisted.  The  patient  was  transferred 
to  the  service  of  Dr.  Delore,  who  made  a  large  costal  resec- 
tion, which  was  followed  by  a  gradual  recovery.  The  success 
of  this  case  was  entirely  due  to  radioscopy. 

Sclerosis  of  the  interlohe. — Dry  pleurisy  of  the  interlobar 
spaces  does  not  usually  present  any  physical  sign.  Clinical 
diagnosis  of  it  is  therefore  absolutely  impossible.  Ana- 
tomically this  pleurisy  ends  in  sclerosis  of  the  interlobe. 
In  this  form  it  no  longer  gives  any  stethoscopic  sign  but  it 
becomes  discernible  by  radioscopic  examination  and  on  this 
account  it  interests  us. 

M.  A.  Beclere  was  the  first  to  draw  attention  to  this  point 
in  1902  in  an  article  in  the  ''Presse  medicale."  He  showed 
that  sclerosis  of  the  interlobe  could  not  be  determined  by 
the  usual  examination  but  that  it  was  necessary  to  follow  a 
certain  technique  if  it  was  to  be  brought  out.  On  account  of 
the  rather  oblique  position  of  the  interlobar  fissure  it  shows 
very  little  thickness  in  the  anterior  or  posterior  examination, 
when  the  tube  is  on  a  level  with  the  middle  of  the  thorax, 
which  is  the  normal  position  for  an  examination. 

The  result  of  this  is  that  it  does  not  give  an  appreciable 
shadow.  It  is  sufficient  to  modify  the  position  of  the  tube 
in  such  a  way  that  the  rays  of  normal  incidence  pass  through 
the  same  axis  of  the  interlobar  space  in  order  to  produce  a 
very  clear  shadow  on  the  screen.  In  fact,  in  this  position 
the  sclerotic  band  is  penetrated  by  the  rays  at  its  greatest 
thickness  and  it  appears  on  the  screen  as  a  linear,  more  or 
less  dense,  opaque  shadow  and  follows  an  oblique  direction 
from  apex  to  base  and  from  without  inward,  parallel  to  that 
of  the  interlobe. 

To  obtain  this  result,  it  is  necessary,  in  the  anterior 
position,  to  raise  the  tube  to  the  height  of  the  head  and, 
in  the  posterior  position,  to  lower  it  to  the  level  of  the  pelvis. 


40  RADIO-DIAGNOSIS:  PLEUR.E 

In  fact,  in  each  of  these  two  positions  the  interlobe  is 
penetrated  by  the  rays  either  from  apex  to  base,  or  vice 
versa,  at  its  point  of  greatest  thickness.  M.  Beclere  has 
demonstrated  this  by  means  of  a  sheet  of  cardboard  placed 
behind  the  screen.  When  this  sheet  is  held  vertically,  it 
does  not  give  any  perceptible  shadow,  but  if  it  is  turned 
slowly  so  that  its  position  becomes  oblique,  it  commences  to 
throw  a  shadow  on  the  screen  and  finally  gives  a  clear, 
opaque,  linear  shadow  with  contours  sharply  defined,  when 
in  the  horizontal  position.  It  is  exactly  the  same  in  regard 
to  the  interlobe,  but  as  this  is  fixed,  the  tube  must  be  moved 
in  order  to  demonstrate  it.  This  form  of  dry  interlobar 
pleurisy  is  found  especially  in  the  tuberculous. 

The  diagnosis  of  interlobar  sclerosis  is  interesting  and 
radioscopic  examination  deserves  the  credit,  for  other 
methods  of  investigation  are  negative;  however,  it  is  of 
very  little  practical  use  and  does  not  show  the  therapeutic 
value  of  demonstrating  a  suppurative  interlobar  process. 

Diaphragmatic  Pleurisy. — Diaphragmatic  pleurisy  is 
not  rare,  but  the  clinical  diagnosis  is  always  difficult;  it 
ought  to  be  investigated  very  carefully.  The  clinical  picture 
with  sudden  onset  which  is  classically  described :  acute  pain, 
distressing  dyspnoea,  hiccoughs,  etc.,  is  most  often  lacking. 
Local  physical  examination  sometimes  gives  little  informa- 
tion. Radioscopy  is  therefore  of  the  greatest  use  in  deter- 
mining these  locations. 

This  type  of  pleurisy  may  be  purulent,  in  which  case  it  is 
rarely  primary  but  usually  secondary  to  an  infection  which 
is  most  often  of  abdominal  origin.  It  may  often  be  serous  or 
dry.  These  two  forms  are  much  more  frequent,  of  an  in- 
sidious nature  and  are  ordinarily  met  with  in  tuberculous 
cases. 

Purulent  diaphragmatic  pleurisy. — This  form  is  the  most 
important.  It  does  not  usually  follow  pulmonary  lesions; 
therefore  the  preservation  of  the  clearness  of  the  overlying 
lung  ought  to  be  studied.  In  exceptional  cases  it  might 
form  following  purulent  pleurisy  of  the  large  cavity,  which 


CIRCUMSCRIBED  AND  ENCYSTED  PLEURISY     41 

later  would  become  encysted.  In  this  case  the  anterior 
pleural  lesions  would  have  obscured  in  certain  measure  the 
corresponding  hemithorax;  but  most  often  it  is  a  distant 
infection  (appendix  abscess,  gastro-intestinal  ulcer  or  cancer, 
lesions  of  annexa,  etc.)  which  determines  this  localization. 

The  clinical  picture  of  it  is  always  serious,  even  without 
the  striking  characteristics  which  are  so  often  lacking:  gen- 
eral health  poor,  tachycardia,  a  markedly  intermittent  tem- 
perature. It  is  assumed  that  there  must  be  local  suppuration. 
The  local  symptoms  (dullness,  absence  of  fremitus  and 
respu'atory  sounds)  are  very  important  when  they  exist,  but 
they  may  pass  unperceived  or  may  be  entirely  lacking.  This 
may  occur  if  the  collection  is  deep,  limited,  and  entirely 
surrounded  by  a  layer  of  healthy  lung. 

Under  these  conditions  radioscopic  examination  assumes 
great  importance.  It  shows  ordinarily  an  opaque  shadow, 
in  the  form  of  a  horizontal  band,  several  fingers  in  width, 
and  situated  at  the  base  of  the  hemithorax.  The  value  of 
this  band  should  be  determined — whether  it  signifies  a  collec- 
tion, and  whether  it  is  above  or  below  the  diaphragm. 

When  the  dark  band  shows  a  clearly  defined  superior 
contour  and  when  the  lung  remains  clear  above,  there  is 
every  indication  of  a  localized  collection. 

If  the  band  does  not  occupy  the  entire  width  of  the  hemi- 
thorax, if  the  external  portion  has  remained  clear  and  the 
costodiaphragmatic  cul-de-sac  permeable,  it  is  located  above 
the  diaphragm,  beyond  any  possible  question. 

If  the  band  occupies  the  entire  width  without  any  lateral 
clear  spaces,  it  is  impossible  on  casual  inspection  to  decide 
the  question. 

Clinically  it  has  been  proposed  to  make  diagnosis  by  punc- 
ture. If  the  discharge  is  greatest  on  inspiration,  the  collec- 
tion is  subdiaphragmatic ;  on  the  contrary,  if  it  is  greatest  on 
expiration,  the  collection  is  above  the  diaphragm.  An  im- 
portant objection  may  be  made  to  these  theories;  that  is,  that 
the  diaphragm  being  immobile,  these  signs  most  often  can- 
not be  determined. 


42  RADIO-DIAGNOSIS:  PLEURA 

Radioscopic  examination  can  furnish  this  information  to 
some  degree.  If  the  band  is  situated  on  the  left,  recourse 
may  be  had  to  inflation  of  the  stomach.  This  technique 
easily  lights  up  the  inferior  surface  of  the  diaphragm,  if  the 
collection  is  above;  and  if  it  is  below,  the  stomach  will  appear 
displaced  to  the  right  or  else  the  air  chamber  will  remain 
either  only  slightly  apparent  or  invisible. 

When  the  band  is  at  the  right,  it  is  confused  with  the 
shadow  of  the  liver  and  it  becomes  quite  impossible  to  dif- 
ferentiate them  radioscopicallj'. 

Finally,  in  a  case  where  the  radioscopic  examination  shows 
a  small,  clear  pocket,  apparently  filled  with  gas,  in  the  middle 
of  the  abnormal  shadow,  this  finding  favors  a  subphrenic 
collection,  unless  an  evacuation  has  previously  been  made. 

Whatever  may  be  the  difficulty  of  exactly  locating  the 
lesion,  either  above  or  below  the  diaphragm,  radioscopic 
examination  will  always  be  able  to  show  the  existence  of  a 
collection  which  ought  to  be  evacuated  in  either  case.  It 
will  indicate  at  what  point  it  is  best  to  approach  it,  and  the 
surgeon  will  determine  through  intervention  whether  the 
origin  of  the  suppuration  was  above  or  below  the  diaphragm. 

Serous  diaphragmatic  pleurisy . — This  form  is  much  more 
frequent  than  the  preceding  and  much  more  insidious  as 
well.  It  occurs  most  often  in  tuberculous  cases,  manifesting 
itself  either  in  the  course  of  the  development  of  pulmonary 
lesions,  or  as  a  terminal  process,  or  as  a  sequela  of  pleurisy  of 
the  large  cavity. 

In  the  greater  number  of  cases  the  overlying  lung  will  not 
have  retained  its  normal  transparency. 

The  following  case  was  observed  by  Bar j  on  clinically  and 
radioscopically  and  later  verified  by  autopsy.  A  man  thirty- 
nine  years  of  age  entered  the  hospital  during  his  service  for 
pulmonary  tuberculosis.  On  examination  he  showed  the  fol- 
lowing signs:  slight  dullness  of  the  apex  and  dullness  of  the 
left  base;  vocal  fremitus  was  markedly  increased  at  the  apex 
and  not  present  at  the  base.  On  auscultation  there  was  heard 
at   the  apex  roughened  inspiration,    prolonged  expiration 


Radiograph  4B 
No.  200.    E.  B.   Male,  .37  years  old.    Chronic  pulmonary  tuberculosis.   Diaphrag- 
matic adhesions  on  right — middle  of  dome. 


Radiograph  5.     SCLEROSIS  OF  THE  INTERLOBE 
A  tuberculous  case  with  advanced  pulmonary  lesions  and  tuberculous  perito- 
nitis— ascitic  type. 

Transverse  opaque  band,  slightly  oblique  from  apex  to  base  and  from  without 
inward,  cuts  through  the  center  of  the  right  hemithorax  in  its  entire  width.  Be- 
sides considerable  enlargement  of  the  right  hilus  shadow,  attached  to  the  median 
shadow  (tuberculosis  of  hilus)  and  diffuse  shadows  in  both  lungs,  more  marked 
and  more  extensive  on  the  right  (pulmonary  lesions). 


CIRCUMSCRIBED  AND  ENCYSTED  PLEURISY     43 

and  rales;  now  and  then  moist  explosive  expiratory  rales. 
At  the  base  the  vesicular  murmur  had  disappeared;  no 
sounds;  no  rales;  no  egophony;  no  aphonic  pectoriloquy. 

Radioscopic  examination  showed  a  diffuse  obscurity  of  the 
whole  left  chest,  greatest  at  the  apex  and  base.  Towards 
the  apex  the  obscurity  extended  to  the  upper  two-thirds  of 
the  chest;  it  was  dense  but  not  homogeneous,  and  in  the 
center  of  the  opaque  zone  there  was  distinguished  a  small, 
irregularly  rounded  clear  area,  the  size  of  a  walnut,  which 
suggested  a  pulmonary  cavity.  At  the  base  the  obscurity 
was  less  extensive  but  more  homogeneous  and  more  compact. 
It  was  continuous  with  the  shadow  of  the  heart,  occupied 


Fig.  8.     LEFT  DIAPHRAGMATIC  PLEURISY 

all  the  inferior  external  side  of  the  hemithorax,  and  com- 
pletely effaced  the  costodiaphragmatic  cul-de-sac.  The 
diaphragm  was  totally  immobilized  on  this  side  and  no 
respiratory  movement  was  perceptible. 

This  shadow,  however,  did  not  show  a  clearly  defined  upper 
contour.  It  was  gradually  effaced,  continuing  imperceptibly 
with  the  gray  tone  of  the  lung  above,  almost  giving  the  im- 
pression of  a  pleurisy  of  the  large  cavity  in  process  of  absorp- 
tion; but  the  findings  obtained  by  clinical  examination  did 
not  favor  this  interpretation. 

Autopsy  showed  that  it  was  an  encysted  serous  diaphrag- 


44  RADIO-DL\GNOSIS:  PLEURA 

matic  pleurisy,  added  to  extensive  pulmonary  tuberculous 
lesions,  with  a  small  cavity,  as  radioscopic  examination  had 
indicated. 

Solid  and  complete  obscurity  of  the  base  in  tuberculous 
cases  with  effacement  of  the  costodiaphragmatic  cul-de-sac 
ought  to  be  suspected,  especially  when  on  clinical  examina- 
tion auscultation  is  negative  at  this  level.  Certainly  exten- 
sive pulmonary  lesions  of  the  base  with  a  dry  pleural  reaction 
and  adhesions  may  give  a  like  image,  but  it  is,  however, 
exceptional  for  the  obscurity  to  be  as  homogeneous  and  com- 
plete as  when  there  exists  at  the  same  time  an  encysted 
effusion. 

Dry  diaphragmatic  pleurisy,  adhesions. — This  form  is  very 
frequent  in  tuberculous  cases;  sometimes  it  is  associated 
with  very  extensive  adhesions  or  even  with  a  total  sym- 
physis; sometimes  it  remains  localized  in  the  diaphragmatic 
region.  Most  often  it  does  not  give  any  clinical  signs;  some- 
times a  little  diminution  of  sonority  and  fremitus  at  the 
base  with  obscurity  of  respiration  and  without  rales  or 
friction. 

Radioscopy  is  very  important  in  detecting  dry  pleurisy 
with  adhesions,  the  investigation  of  which  has  become  in- 
dispensable since  Forlanini's  method  of  treatment  of  pul- 
monary tuberculosis.  Before  resorting  to  artificial  pneu- 
mothorax it  is  absolutely  necessary  to  be  informed  regarding 
the  mobility  of  the  lung  and  to  be  sure  that  pleural  adhe- 
sions will  not  prevent  the  needle  from  penetrating  the  pleura 
and  will  not  prevent  the  retraction  of  the  lung,  which  is 
indispensable  for  successful  treatment. 

The  principal  radioscopic  signs  of  this  localization  are: 
immobilization  and  deformation  of  the  diaphragmatic  dome 
and  the  appearance  of  a  double  contour  with  diminution  or 
disappearance  of  the  costodiaphragmatic  cul-de-sac. 

T\nien  solid  adhesions  exist,  the  contour  of  the  diaphrag- 
matic dome  is  almost  always  deformed.  Instead  of  present- 
ing a  regularly  rounded  convexity,  the  line  of  demarcation 
becomes  either  horizontal  or  oblique  from  top  to  bottom  and 


CIRCUMSCRIBED  AND  ENCYSTED  PLEURISY     45 

from  without  inward,  or  angular  so  that  the  sharp  angle 
occupies  the  middle  part  of  the  deformed  curve. 

This  deformation  is  accompanied  usually  by  more  or  less 
complete  immobilization,  and  it  is  not  uncommon  to  see  the 
respiratory  movements  entirely  suppressed,  while  they  per- 
sist on  the  opposite  side.  The  costodiaphragmatic  cul-de- 
sac  may  be  completely  effaced,  but  often  it  is  only  reduced 
and  deformed.  Finally,  when  the  symphysis  is  complete, 
when  the  pleural  layers  are  thickened  or  when  a  more  or  less 
thick  exudate  is  formed  between  them,  the  lung  becomes 
compressed  above  the  diaphragm  and  between  the  pul- 
monary clearness  and  the  dark  contour  of  the  arch  a  gray 
zone  corresponding  to  this  exudate  is  seen,  which  on  the 


Fig.  9.     RIGHT  MEDIASTINAL  PLEURISY 

screen  or  the  radiographic  plate  appears  as  a  quite  char- 
acteristic double  contour.  Barjon  observed  a  case  of  this 
kind  which  was  verified  by  autopsy  in  a  chronic  tuberculous 
patient.    The  radiograph  of  this  case  is  given. 

Mediastinal  Pleurisy. — Mediastinal  pleurisy  is  rare. 
It  may  be  purulent  or  serofibrinous.  It  may  be  dry  without 
effusion.  Of  these  different  forms  the  first  is  much  the  most 
important  and  the  most  serious.  Left  to  itself,  it  may  result 
fatally.    It  necessitates,  therefore,  intervention,  which  may 


46 


RADIO-DIAGNOSIS:  PLEURA 


be  successful,  provided  it  is  not  resorted  to  too  late.  It  is 
important  to  make  the  diagnosis  as  early  as  possible. 

The  two  other  forms  are  less  serious.  They  are  ordinarily 
cured  by  medical  means.  In  the  dr}"  form  it  is  sufficient  to 
apply  a  counter-u-ritant  over  the  inflamed  zone,  without  any 
need  of  exactness.  In  the  serofibrinous  form,  puncture  is 
rarely  necessary;  the  cure  is  spontaneous. 

Mediastinal  pleurisy  with  effusion. — The  collection  may  be 
present  in  the  anterior  or  in  the  posterior  mediastinum;  it 
may  be  unilateral  or  bilateral.  It  may  be  combined  w^ith 
diaphragmatic  pleurisy  or  with  pericardial  effusion. 

What  in  general  may  be  considered  characteristic  of 
radioscopic  examination  in  mediastinal  pleurisy  is  the  fact 


Fig.  10.    LEFT  MEDIASTINAL  PLEURISY 

that  the  abnormal  shadow  which  it  reveals  is  always  super- 
added to  the  median  shadow.  It  deforms  and  increases  this 
shadow  at  a  point  differing  according  to  its  location. 

In  the  posterior  mediastinum  it  is  seen  as  a  dark  band 
adherent  to  the  vertebral  shadow  and  occupying  all  the 
inferior  part  of  the  thorax  from  the  hilus  of  the  lung  to  the 
diaphragm.  In  the  anterior  mediastinum,  on  the  right,  it  is 
seen  as  an  obscure  triangle,  the  apex  of  which  corresponds  to 
the  hilus  of  the  lung  and  the  base  to  the  diaphragm;  on  the 
left,  it  is  like  an  enlarged  aortic  shadow  and  surmounts  that 


Radiograph  6.     LEFT   DIAPHRAGMATIC   PLEURISY  IN   PULMONARY 

TUBERCULOSIS 

Diffuse  shadows,  scattered  mottling  in  the  right  lung.  More  important  ob- 
scurity of  the  upper  two-thirds  of  the  left  lung  with  intervening  clear  zones  (cav- 
ities). At  the  left  base:  very  opaque  limited  shadow  situated  above  the  diaphragm, 
the  outline  of  which,  as  well  as  that  of  the  heart,  is  effaced.  Suppression  of  re- 
spiratory movements. 

Clinical  signs:  cavity  indications  in  the  upper  two-thirds  of  the  left  lung;  at  the 
base  flatness  with  absence  of  fremitus  and  obscured  respiration. 


Radiograph  7. 


DIAPHRAGMATIC    DRY    PLEURISY 
BASE  ^yITH  ADHESIONS 


AT    THE    RIGHT 


Elevation  and  deformation  of  the  diaphragmatic  dome  at  the  right.  Double 
outline  of  the  diaphragm.  Complete  effacement  of  the  costodiaphragmatic  sinus. 
Immobilization  of  the  diaphragm. 

Autopsy. — Complete  diaphragmatic  adhesions  of  the  right  base.  Between  the 
lung  and  the  diaphragm  the  presence  of  a  considerable  depth  of  organized  exudate 
corresponding  to  the  grayish  tone  which  surmounts  the  diaphragm.  This  explains 
the  double  contour  seen  on  the  print. 


CIRCUMSCRIBED  AND  ENCYSTED  PLEURISY     47 

of  the  heart  as  in  aneurysm  of  the  descending  portion.  Such 
at  least  is  the  theoretical  description.  In  reality,  things  are 
not  always  as  clear  as  that,  and  to  detect  mediastinal 
pleurisy  it  is  necessary  to  compare  the  clinical  symptoms 
with  the  radiological  indications. 

Mollard  and  Rebattu  reported  a  case  with  a  purulent 
collection  which  involved  the  mediastinum  anteriorly  and 
posteriorly  on  the  left  side.  Diagnosis  was  based  on  the 
following  considerations:  In  spite  of  an  effusion  which  did 
not  seem  very  abundant,  marked  dyspnoea  was  present  and 
especially  a  marked  displacement  of  the  heart  to  the  right. 
It  therefore  seemed  that  the  fluid — rare  in  the  large  cavity — 
was  more  abundant  and  encysted  in  the  mediastinal  region. 


Fig.  11.     PSEUDO  PERICARDIAL  FORM.     MEDIASTINAL  PLEURISY 

On  the  other  hand,  radioscopic  examination  showed,  in  the 
middle  of  a  general  obscurity  of  the  left  hemithorax,  except- 
ing only  the  apex,  a  denser  shadow  visible  at  first  in  front, 
in  contact  with  the  compressed  heart,  then  at  the  same  time 
in  front  and  in  back  in  the  mediastinum.  A  slight  evacua- 
tion followed  by  a  rather  foetid  expectoration  soon  indicated 
the  nature  of  the  collection.  After  this  series  of  findings 
diagnosis  was  completely  and  definitely  made  and  soon 
verified  by  surgical  intervention. 


48  RADIO-DLVGNOSIS:  PLEUR.E 

Devic  and  Savy  (Revue  de  medecine,  1910)  reported  their 
study  of  mediastinal  pleurisy  from  a  very  general  point  or 
view.  They  have,  in  particular,  included  a  detailed  chapter 
on  radioscopic  examination  by  Destot. 

These  authors  lay  down  the  principle  that  in  order  to 
make  a  radiological  diagnosis  it  is  not  necessary  to  have 
complex  cases  in  which  total  obscurity  of  the  radioscopic 
pulmonary  field  is  caused  by  old  and  extended  pleurisy 
lesions. 

The  anterior  forms  are  especially  studied  and  distinction 
is  made  between  slight  and  marked  effusions.  Slight  effu- 
sions give  a  lightly  shaded  band  which  doubles  the  cardiac 
shadow;  it  is  unilateral  or  bilateral,  more  frequent  on  the 
right,  especially  in  infants.  Marked  effusions,  usually 
anterior,  take  the  pseudo-pericardial  forms  and  are  much 
more  interesting  from  a  radio-diagnostic  point  of  view.  The 
shadow  shown  on  the  screen  is  quite  like  that  of  pericarditis 
with  marked  effusion.  It  is  therefore  necessary  to  make  a 
diagnosis  between  the  two. 

Destot  points  out  a  sign  which  to  him  seems  of  great  value, 
namely,  the  disappearance  of  the  heart  beats  in  mediastinal 
pleurisy  and,  on  the  contrary,  their  preservation  in  pericar- 
ditis with  marked  effusion. 

Investigators  do  not  agree  on  this  point.  Beclere  points 
out  as  a  sign  of  pericarditis  with  marked  effusion  the  diminu- 
tion or  the  disappearance  of  cardiac  pulsations.  Destot,  on 
the  contrary,  applying  the  physical  principle  of  the  in- 
compressibility  of  fluids,  admits  that  the  beating  of  the  heart 
is  always  visible  in  pericarditis  alone — that  is  to  say,  when 
not  accompanied  by  any  pleural  reaction.  In  support  of 
this  he  cites  a  case  of  Berard  and  Pehu's  of  pericarditis  con- 
taining three  liters  of  fluid,  in  which  the  pulsations  of  the 
cardiac  shadow  were  clearly  shown  and  concludes;  when 
pericardial  effusion  gives  no  pulsation  in  the  shadow  pro- 
duced, there  is  adjacent  mediastinal  pleurisy  associated  with 
pericarditis.    This  association  is  in  fact  quite  frequent. 

In  cases  where  it  would  be  difficult  to  know  exactly 


CIRCUMSCRIBED  AND  ENCYSTED  PLEURISY     49 

whether  there  exists  or  not  a  superadded  pericarditis,  Destot 
advises  an  indirect  procedure  by  which  the  stomach  is 
sUghtly  inflated.  The  inferior  surface  of  the  diaphragm  is 
then  clear.  If  at  this  level  an  abnormal  protuberance 
exists — a  convexity  under  the  inferior  surface  of  the  im- 
mobile diaphragm,  it  is  concluded  that  a  superadded  peri- 
carditis is  present,  for  the  inferior  surface  of  the  heart  is  not 
enclosed  in  the  pleura  and  this  convexity  can  be  due  only  to 
an  increase  of  pressure  in  the  pericardium. 

Dry  mediastinal  'pleurisy. — This  form  does  not  haye  great 
interest  and  appears  on  radioscopic  examination  as  an  ab- 
normal shadow  superadded  to  the  median  shadow  without 
form  or  very  exact  outline.  It  is  often  taken  for  chains  of 
glands  in  the  neighborhood  of  the  hilus  and  gives,  prin- 
cipally on  the  right,  a  more  extensive  shadow  of  triangular 
form,  often  difficult  of  interpretation. 

Pleurisy  of  the  Hilus  Region.  The  Hilus  Open 
Space  of  the  Pleura. — This  form  of  pleurisy  is  not  well 
known.  That  is  because  it  does  not  give  sufficient  cfinical 
signs  to  attract  attention  because  it  is  of  very  short  duration. 
It  is  cured  very  quickly  or  its  form  changes,  the  purely 
hilus  form  passing  most  often  unnoticed. 

One  thing  only  holds  the  attention  of  the  radiologist  and 
that  is  the  existence  of  abnormal  images  localized  in  the 
region  of  the  hilus.  The  interpretation  of  these  images  is 
impossible  by  radioscopy  alone,  but  due  to  clinical  co- 
operation, a  reasonable  explanation  can  be  given  which  the 
development  justifies. 

Radioscopic  examination  will  have  accomplished  much 
by  showing  the  presence  of  these  partial  pleurisies,  which 
certainly  will  become  less  rare  as  they  become  better  known. 

Personally,  Bar j  on  observed  two  cases  of  pleurisy  of  the 
hilus  region.  In  one  case  the  pleurisy  remained  limited,  was 
evacuated  spontaneously  through  the  bronchi  and  rapidly 
cured.  In  the  other  case,  the  pleurisy,  at  first  of  the  hilus, 
affected  the  interlobe  secondarily,  became  transformed  into 
interlobar  pleurisy,  and  still  later,  affected  the  entire  pleural 


50  RADIO-DIAGNOSIS:  PLEUR.E 

cavity.  These  three  stages  were  very  well  followed  clinically 
and  radiologically.  Recently  Cade  and  Goyet  reported 
(Societe  medicale  des  hopitaiix  de  Lyon,  June,  1913)  a  case 
which  ought  to  be  added  to  this  group;  the  pleurisy,  at  first 
limited  to  the  region  of  the  hilus,  affected  the  interlobar 
cavity  secondarily. 

The  analj^sis  of  these  three  cases  serves  to  outline  the 
clinical  and  radiological  history  of  these  pleurisies. 

The  hilus  open  space  of  the  pleura. — Anatomically  the  re- 
gion of  the  hilus  is  one  of  the  most  complex  parts  of  the 
pleura.  In  the  hilus  is  a  sort  of  open  space,  found  at  the 
junction  of  all  the  secondary  diverticula  of  the  pleura. 
The  large  pleural  cavit}^,  the  interlobes,  the  anterior  and  pos- 
terior spaces  of  the  mediastinal  pleura  all  end  in  the  neighbor- 
hood of  the  hilus.  The  diaphragmatic  pleura  alone  does  not 
show  direct  connection  with  the  open  space. 

This  region  of  the  hilus  undergoes  many  changes.  The 
hilus  itself,  the  extremities  of  the  pulmonary  lobes,  cir- 
cumscribe a  whole  series  of  pleural  folds,  forming  small 
grooves  or  small  potential  spaces  which  adhesions  may 
easily  cut  off.  The  adjoining  organs,  in  particular  the  aorta, 
the  artery,  pulmonary  veins  and  vena  cava,  by  the  compres- 
sion they  exercise  locally  on  these  pleural  layers  may  facil- 
itate the  formation  of  rapid  adhesions  on  an  inflamed  pleura. 
It  is  easy  to  understand  therefore  that  in  this  region  small 
pleural  diverticula  may  be  isolated  and  become  the  seat  of 
limited  partial  effusions. 

Causes  of  infection  are  not  wanting  in  this  region, — the 
proximity  of  the  large  bronchi  which  bring  it  into  direct  com- 
munication with  the  outer  air;  the  presence  of  numerous 
tracheo-bronchial,  bronchial  and  hilus  glands  which  are 
there  for  the  express  purpose  of  serving  as  a  barrier  to 
infections,  but  which  may,  in  their  turn,  transmit  them; 
finally,  the  oesophagus  which,  through  its  proximity  may 
become  the  point  of  departure  of  disease  as  in  the  case  ob- 
served by  Cade  and  Goyet. 

All  these  reasons  explain  the  possibility  of  pleural  localiza- 


CIRCUMSCRIBED  AND  ENCYSTED  PLEURISY     51 

tions  limited  to  the  hilus  region.    Radioscopy  and  clinical 
methods  unite  in  demonstrating  their  existence. 

Case  1. — Acute  febrile  condition.  Sudden  appearance  of  a 
purulent  expectoration  with  extremely  foetid  breath.  Radioscopic 
shadow  gray,  diffused,  localized  in  the  region  of  the  right  hilus. 
Purulent  encysted  pleurisy  of  the  anterior  region  of  the  hilus. 
Rapid  spontaneous  recovery. 

This  patient,  fifty-two  years  of  age,  was  referred  to  Barjon  by 
Gallavardin.    Development  in  3  phases. 

1st  phase  from  the  2nd  to  the  8th  of  May:  malaise,  slight 
temperature,  no  cough.  2nd  phase  from  the  8th  to  the  11th  of 
May:  severe  chills,  severe  stitch  in  the  side,  the  temperature  rose 
to  40°  C,  cough,  brownish  expectoration.  3rd  phase  beginning 
May  11th:  sudden  appearance  of  very  foetid  breath  and  expectora- 
tion, undeniably  purulent,  abundant,  without  true  evacuation. 

Radioscopic  examination. — This  could  only  be  made  after 
spontaneous  evacuation  of  the  collection.  It  showed  a  rather  ex- 
tended shadow,  irregular,  of  moderate  opacity,  situated  in  the 
vicinity  of  the  right  hilus.  It  was  separated  from  the  median 
shadow  by  a  clear,  narrow  band  and  had  neither  exact  form  nor 
contours. 

It  suggested  a  small  focus  of  encysted  pleurisy  emptjdng  into 
the  bronchi,  or  a  pulmonary  gangrene  lesion.  Radioscopy  affirmed 
the  location  but  gave  no  indication  of  its  nature. 

Clinically  very  localized  physical  signs  were  present  in  addition 
to  the  radioscopic  image:  slight  dullness  in  the  second  intercostal 
space  at  the  sternal  border;  percussion  in  this  area  provokes  a  fit 
of  coughing  with  purulent  expectoration;  extremely  foetid  breath; 
nothing  on  auscultation. 

Rapid  development  and  recovery;  in  four  days  the  temperature 
fell  again  to  normal;  patient  discharged  cured  on  the  15th  day. 

Interpretation. — Rapid  development,  the  absence  of  all  impor- 
tant signs  on  auscultation,  the  sudden  and  simultaneous  appear- 
ance of  the  foetid  breath  and  purulent  expectoration,  the  sponta- 
neous improvement  taking  place  after  the  evacuation  of  the  foetid 
purulent  collection,  the  definite  cure  obtained  within  a  few  days 
afterward,  almost  without  treatment;  all  point  in  favor  of  a  small 
encysted  pleurisy  in  the  region  of  the  hilus.  Only  one  other  theory 
might  be  considered — that  of  a  focus  of  pulmonary  gangrene  on 


52  RADIO-DL\GNOSIS:  PLEURAE 

account  of  the  odor.  But  in  such  a  case  the  foetid  breath  precedes 
expectoration,  stethoscopic  signs  are  more  important,  the  general 
condition  more  serious,  the  cure  is  not  obtained  so  quickly  and 
without  treatment. 

Case  II. — Acute  feljrile  condition.  Purulent  encysted  pleurisy 
of  the  anterior  region  of  the  left  hilus.  Secondary  extension  to 
the  whole  interlobe.  Evacuation  and  slow  extension  to  the  large 
pleural  cavitj'.    Surgical  intervention,  cure. 

This  patient,  fifty-nine  years  of  age,  had  for  about  one  month  a 
persistent  fitful  cough,  painful,  with  hoarseness.  Signs  of  diffuse 
bronchitis  and  fever,  38.8°  C. 

A  first  radioscopic  examination,  June  5th,  shows  on  the  left 
in  the  region  of  the  hilus,  between  the  aortic  arch  and  the  heart, 
an  opaque  shadow  with  well  defined  contours,  representing  roughly 
the  form  of  a  kidney.  This  shadow  merges  below  into  the  shadow 
of  the  heart,  from  which  it  is  difficult  to  separate  it,  but  on  the 
side  of  the  lung  these  contours  are  very  clear. 

Another  examination  on  the  20th  of  June  is  quite  different. 
In  the  interval  the  condition  has  become  worse,  the  temperature 
has  reached  39.5''  C,  the  expectoration  has  become  purulent  and 
bloody.  The  dullness  has  extended  under  the  left  clavicle.  Aus- 
cultation gives  numerous  broncho-pneumonic  foci  with  fine  rales. 
The  radioscopic  image  is  very  different  from  that  observed  fifteen 
days  before. 

A  clearly  defined,  very  opaque  shadow  is  present,  occupying 
the  whole  middle  portion  of  the  left  lung  and  extending  from  one 
border  to  the  other  throughout  the  entire  width  of  the  hemithorax. 
The  superior  and  inferior  borders  are  slightly  uneven.  The  diag- 
nosis of  interlobar  pleurisy  is  apparent. 

There  has  been  therefore  a  change  from  pleurisy  of  the  hilus 
into  interlobar  pleurisy. 

No  intervention  could  be  made  at  this  stage;  it  was  only  two 
and  a  half  to  three  months  afterwards  that  an  abundant  evacuation 
was  produced  and  that  from  the  effect  of  rupture  of  adhesions  in 
a  third  phase,  the  large  pleural  cavity  was  invaded. 

A  first  intervention  drained  the  large  pleura;  later  a  second 
intervention  was  necessary  on  the  encysted  interlobar  focus  which 
had  not  been  sufficiently  emptied.  The  patient  had  a  perfect 
recovery. 

The  development,  extension  and  repeated  intervention  confirmed 
the  diagnosis. 


CIRCUMSCRIBED  AND  ENCYSTED  PLEURISY     53 

In  connection  with  these  two  cases  of  Barjon's  the  case  of 
Cade  and  Goyet's  is  here  included. 

Case  III  (Cade  and  Goyet).— Wound  of  the  oesophagus  by  a 
bony  foreign  body.  Poor  general  condition,  fever,  chills,  infection. 
Hemoptysis,  purulent  expectoration,  then  true  vomica.  It  is  a 
question  of  an  encysted  pleurisy. 

Radioscopic  examination  made  after  the  evacuation  shows  a 
light  obscurity  in  the  middle  part  of  the  left  lung  above  the  heart. 


Fig.  12.  HILUS  PHASE  Fig.  13.     INTERLOBAR  PHASE. 

Two  phases  of  an  interlobar  pleurisy  fifteen  days  apart. 

The  posterior  space,  on  obUque  examination,  appears  opaque  in 
its  middle  portion. 

Barjon  thinks  this  case  could  be  interpreted  as  an  encysted 
pleurisy  of  the  posterior  region  of  the  left  hilus,  affecting  perhaps 
secondarily  the  posterior  space  of  the  mediastinal  pleura. 

In  fact,  according  to  radioscopic  examination,  neither  the  large 
pleura  nor  the  interlobe  seem  to  have  been  involved.  As  the 
evacuation  was  sufficiently  abundant,  it  might  be  asked  whether 
there  has  not  been  secondary  involvement  of  the  posterior  medias- 
tinal space.  The  image  of  this  localization  easily  passes  unnoticed, 
covered  as  it  is  by  the  shadow  of  the  heart.  On  the  other  hand, 
the  oesophageal  origin  of  the  infection  would  easily  explain  this 
extension. 

The  posterior  localization  of  the  empyema  seems  confirmed 
clinically  by  stethoscopic  signs,  friction,  rales  and  expiratory 
sounds  which  were  noticed  behind  in  the  sub-spinous  fossa. 


54  RADIO-DLVGNOSIS:  PLEUR.E 

These  three  facts  establish  the  pathological  historj'-  of  encysted 
pleurisy  of  the  hiliis. 

Location. — Encysted  empj-ema  maj"  develop  in  the  region 
of  the  hiliis,  either  on  the  right  (Case  I),  or  on  the  left 
(Cases  II  and  III).  It  may  be  localized  in  one  of  the  many 
folds  of  this  pleural  open  space,  at  the  entrance  of  which 
arise  all  the  diverticula  of  the  pleura. 

It  may  be  localized  either  in  front  of  the  hilus  (''hilaire 
anterieur");  Cases  I  and  II  have  this  origin;  or  behind 
("hilaire  posterieur")  as  in  Case  III. 

Origin. — It  is  due  to  an  infection,  the  origin  of  which  is 
often  bronchial  or  glandular  in  the  anterior  location,  and 
which  may  also  be  of  oesophageal  origin  in  the  posterior 
location.    Many  other  causes  may  intervene  besides. 

Development. — A\Tien  early  and  sufRciently  firm  adhesions 
have  had  tmie  to  become  established,  empyema  may  remain 
localized  in  the  region  of  the  hilus,  develop  there  and  without 
progressing  undergo  resolution  (Case  I). 

At  other  times  the  affection  develops  at  two  different 
places.  It  remains  at  first  localized  in  the  region  of  the 
hilus,  then  it  may  secondarily  affect  an  adjoining  space  of 
the  pleura.  In  Case  II,  anterior  location,  the  empyema  has 
affected  the  whole  interlobe  and  the  hilus  pleurisy  is  changed 
into  an  interlobar  pleurisy.  In  Case  III,  posterior  location, 
the  extension  seems  rather  to  have  taken  place  in  the  poste- 
rior space  of  the  mediastinal  pleura. 

The  extension  could  have  taken  place  just  as  well  in  the 
large  pleural  cavity,  as  occurred  gradually  in  Case  II,  in  the 
course  of  a  third  stage.  So  that  pleurisy  of  the  hilus  may 
sometimes  precede  any  form  of  pleurisy,  whether  total,  inter- 
lobar, or  mediastinal.  As  the  true  hilus  phase  is  short  and 
as  it  gives  only  very  slight  local  symptoms,  it  may  easily  pass 
unnoticed. 

Raclioscopic  diagnosis. — Radioscopic  examination  alone 
demonstrates  these  localizations.  Pleurisy  of  the  hilus  is 
shown  on  the  screen  as  limited  shadows,  the  appearance  of 
which  differs  according  to  whether  examination  was  made 


CIRCUMSCRIBED  AND  ENCYSTED  PLEURISY     55 

before  or  after  the  evacuation  of  the  collection  in  the 
bronchi. 

Before  evacuation  a  very  opaque,  distinct  shadow  with 
well  marked  contours  is  shown.  This  is  so  in  Case  II,  in 
which  this  shadow  situated  on  the  left  border  of  the  median 
shadow  might  suggest  a  mediastinal  tumor.  The  second 
examination,  showing  the  change  into  interlobar  pleurisy 
decided  the  diagnosis. 

After  evacuation  the  image  is  less  opaque,  the  contours  less 
sharply  defined.  It  is  sufficient,  however,  to  attract- atten- 
tion to  the  localization  at  the  hilus.  It  would  seem  probable 
that  in  such  a  case  there  might  be,  after  the  evacuation,  a 
hydroseric  image  suggesting  partial  pneumothorax.  Never- 
theless it  is  not  produced  either  in  Case  I  or  in  Case  III. 

It  is  therefore  necessary  that  radiologists  learn  to  discuss 
the  interpretation  of  abnormal  shadows  of  the  hilus  region 
and  that  a  place  be  given  to  encysted  pleurisy  of  the  open 
space  of  the  hilus  in  addition  to  mediastinal  tumors,  gland- 
ular masses,  limited  pulmonary  lesions. 


CHAPTER  III 
PNEUMOTHORAX 

PNEUMOTHORAX  occurs  anatomically  through  the 
penetration  of  air  or  gas  into  the  pleura.  If  adhe- 
sions do  not  exist  between  the  two  layers  of  the  pleura,  the 
gas  fills  the  cavity,  compressing  the  lung  towards  the  hilus. 
A  series  of  radiological  images  of  the  thorax  results  which 
have  a  characteristic  appearance  and  which  will  be  described 
presentl3\ 

Clinically  a  distinction  is  made  by  certain  investigators 
between  open  pneumothorax,  closed  pneumothorax  and 
vahTilar  pneumothorax.  Open  pneumothorax  is  that  in 
which  the  cavity  communicates  with  the  exterior  through  an 
intermediary  bronchial  fistula.  Closed  pneumothorax  is  that 
which  has  no  communication  with  the  exterior.  Vahoilar 
pneumothorax  would  be  that  which  shows  an  intermittent 
communication  with  the  exterior.  The  fistula  would  in  some 
way  be  closed  by  a  valve  which  permits  the  entrance  of 
additional  quantities  of  air  through  the  force  of  expiratory 
pressure,  but  checks  its  outlet.  In  this  way,  the  tension  of 
so-called  valvular  pneumothorax  would  go  on  increasing  and 
would  give  place  to  serious  results  from  suffocation.  There 
seems  to  have  been  much  criticism  of  this  mechanism  which 
has  been  proved.  There  is  no  exact  information  regarding 
the  state  of  tension  in  so-called  valvular  pneumothorax. 
Netter  gives  as  an  average  the  following  pressures : 
Open  pneumothorax  =  atmospheric  pressure 
Closed  pneumothorax  =  — 7  inspiration  +  3  expiration 
Vahnilar  pneumothorax  =  — 1  inspiration  -f  5  expiration. 
Bard  in  his  study  of  pressures  indicates  as  the  maximum 
-|-  8  and  -f  10.  Bar j  on  does  not  believe  that  higher  pressures 
than  these  have  been  recorded.    These  pressures  are  greatly 

56 


PNEUMOTHORAX  57 

exceeded  in  artificial  pneumothorax,  in  the  course  of  which 
the  exact  measurements  attain  pressures  of +  15  + 18  +  22 
and  even,  exceptionally,  +35  +40  and  +  45  ("Bernard) . 
Very  marked  displacement  of  the  heart  and  mediastinum  is 
found  to  which  the  patients  readily  accommodate  them- 
selves. These  excessive  pressures  do  not  seem  ever  to  have 
caused  the  serious  results  of  suffocation  that  have  been 
attributed  to  valvular  pneumothorax.  Bard  has  refuted 
this  theory  of  valvular  mechanism  and  shown  that  the  air 
could  not  accumulate  under  pressure  in  the  pleura  by  means 
of  a  valvular  fistula.  It  is  therefore  necessary  to  find  an- 
other cause  to  explain  these  mishaps. 

So-called  suffocating  pneumothorax  ordinarily  occurs  in 
the  tuberculous;  respiratory  difficulties  are  immediate  and 
follow  the  harsh  penetration  of  a  certain  quantity  of  air  into 
an  inflamed  and  sensitive  pleura.  This  air  is  accompanied  by 
septic  products  arising  from  the  open  tuberculous  lesion. 
An  active  reaction  of  the  pleura  results  which  provokes  reflex 
difficulties  comparable  to  those  noticed  following  certain  un- 
fortunate cases  of  artificial  pneumothorax  or  even  of  simple 
punctures  which  have  caused  sudden  death.  If  the  lungs 
are  already  affected  by  deep  and  extensive  lesions,  if  the  field 
of  hematosis  is  reduced  to  a  large  extent,  equilibrium  is  not 
re-established  and  the  patient  succumbs  to  asphyxia.  This 
occurred  in  the  two  cases  of  Bouveret's  (Lyon  med.,  1888). 

It  seems  indeed  that  the  increase  of  pressure,  which  more- 
over has  not  been  proved,  as  it  has  never  been  measured 
under  such  circumstances,  ought  not  to  be  held  responsible. 
In  fact,  suffocating  pneumothorax  remains,  but  valvular 
pneumothorax  does  not  exist, 

Radiologically  no  distinction  can  be  made  between  these 
different  forms  of  pneumothorax.  It  seems  logical  to  make 
an  etiological  division  and  consider  the  two  principal  forms: 

Spontaneous  pneumothorax  which  is  usually  open. 

Provoked  or  artificial  pneumothorax  which  is  usually 
closed. 

Each  of  these  forms  may  be  total,  limited  or  encysted  ac- 


58  RADIO-DIAGNOSIS:  PLEURA 

cording  to  whether  the  large  pleural  cavity  is  free  of  adhe- 
sions or  whether,  on  the  contrary,  it  is  divided  and  sep- 
arated into  secondary  compartments. 

Spontaneous  Pneumothorax. — Spontaneous  pneumo- 
thorax is  found  most  often  in  the  tuberculous.  It  may  be 
produced  in  the  course  of  an  emphysema  through  rupture  of  a 
vesicle.  It  may  follow  a  traumatism,  a  vomica  of  pleural 
origin,  or  may  be  due  to  quite  other  mechanism. 

It  rarely  remains  a  true  pneumothorax.  In  this  case  it 
resembles  artificial  pneumothorax,  which  will  be  described 
further  on.  It  becomes  complicated  more  or  less  rapidly  by 
an  effusion  which  may  be  serous,  sero-hematic  or  purulent. 
The  coexistence  of  this  double  effusion — gaseous  and  fluid — 
in  the  middle  of  the  pleura  causes  the  formation  of  quite 
characteristic  radiological  images,  which  will  now  be  con- 
sidered. 

The  pleural  cavity  appears  under  a  very  different  form 
from  that  which  it  shows  in  pleurisy.  In  the  upright  position 
the  fluid  effusion,  on  account  of  its  weight,  occupies  the  lower 
part  of  the  pleura;  the  gaseous  effusion  is  localized  in  the 
upper  part.  The  first  presents  a  complete  opacity;  the 
second,  a  very  sharp  clearness.  The  contrast  between  the 
two  is  therefore  striking.  A  perfectly  clear  straight,  horizon- 
tal line  divides  them;  it  corresponds  to  the  fluid  surface  which 
forms  an  absolutely  exact  line  of  level.  The  hemithorax  ap- 
pears then,  according  to  the  classic  comparison,  as  a  bottle 
half  full  of  ink. 

The  mobility  of  the  fluid  surface  is  shown  by  manipula- 
tion. If  the  patient  is  inclined  either  to  the  right  or  left,  the 
body  of  fluid  is  seen  to  be  displaced  on  the  same  side  while 
the  surface  remains  always  horizontal,  the  line  of  level  per- 
fectly straight. 

If  the  patient  is  mobilized  and  is  forcibly  shaken,  the 
fluid  is  seen  to  be  actively  agitated — waves  appearing  on  its 
surface  and  striking  against  the  walls.  This  is  the  Hippo- 
cratic  succession  phenomenon  produced  before  the  eyes  of 
the  observer. 


Radiograph  8.     ENCYSTED  EMPYEMA  OF  THE  RIGHT  HILUS  REGION 
Extensive  diffuse  obscurity  of  the  entire  region  of  the  right  hilus  without  def- 
inite outline.    The  radiograph  could  only  be  made  after  the  evacuation  of  the  pus. 


Radiograph  9.  RIGHT  SPONTANEOUS  PYOPNEUMOTHORAX  IN  A 
TUBERCULOUS  PATIENT 
Pyopneumothorax  with  medium  effusion,  the  line  of  level  horizontal  and  mobile. 
The  right  lung  retracted  towards  the  hilus  remains  adherent  and  obscure  through- 
out the  whole  region  of  the  apex.  Very  appreciable  displacement  of  the  heart  and 
mediastinum  to  the  left.  Left  pulmonary  lesions  already  very  apparent;  obscurity 
of  the  apex,  scattered  mottlings. 


Radiograph  10.  ARTIFIC^IAL  PNEUMOTHORAX  FOR  TUBERCULOSIS 
OF  THE  RIGHT  LUNG 

Complete  detachment  of  the  lung  except  in  the  extreme  apex.  Lung  retracted 
towards  the  hilus  in  complete  collapse.  Displacement  of  the  heart  and  mediastinum 
to  the  left.  Elongation  of  the  right  hemithorax,  enlargement  of  intercostal  spaces, 
lowering  and  flattening  of  the  diaphragm.  Movement  of  balance.  Inspiratory 
displacement  of  the  mediastinum. 

Auscultation — Pneumothorax  signs.  Amphoric  breathing,  metallic  tinkling, 
brassy  sounds. 


Radiograph  11.  ARTIFICIAL  PNEUMOTHORAX  WITH  INCOMPLETE 
DETACHMENT  OF  THE  LEFT  LUNG 

The  left  lung  has  remained  adherent  to  the  apex  and  in  the  axillary  region;  at 
the  base  a  pulmonary  "tongue"  has  remained  adherent  to  the  diaphragm  at  the 
left  of  the  heart. 

The  pneumothorax  is  made  up  of  two  parts, — a  large  lateral  air  chamber  occupy- 
ing all  the  side  from  the  axilla  to  the  diaphragm,  and  a  small  chamber  situated 
above  and  inward  against  the  vertebral  column  below  the  clavicle.  Displacement 
of  the  heart  and  mediastinum. 


4 


PNEUMOTHORAX  59 

During  this  time,  the  lung  also  has  undergone  marked 
modifications.  Compressed  by  the  double  effusion — fluid 
and  gaseous — it  retracts  towards  the  hilus,  if  adhesions  do 
not  prevent  this  movement.  Its  volume  therefore  becomes 
greatly  reduced;  it  appears  as  a  stump,  the  contours  of  which 
are  obscured  by  the  fluid  effusion  but  appear  clearly  in  the 
gaseous  zone.  In  fact,  the  compressed  lung,  having  re- 
tracted, is  emptied  in  large  part,  if  not  totally,  of  the  air  that 
it  contained.  Its  parenchyma  is,  so  to  speak,  condensed;  it 
has  become  much  less  transparent  and  its  image  appears 
distinctly  on  the  clear  background  of  the  gaseous  pocket. 

When  the  pneumothorax  is  total,  when  no  adhesions  re- 
main, the  lung  appears  as  a  longitudinal  band,  which  is  more 
or  less  broad  and  joins  the  median  shadow.  But  adhesions 
modify  this  image  infinitely — the  lung  may  be  fixed  either  at 
the  apex,  laterally,  or  at  the  base,  and  in  each  case  a  new 
image  is  shown. 

All  these  modifications  of  the  intra-thoracic  equilibrium 
necessarily  influence  the  walls  of  the  thoracic  cavity,  but 
more  particularly  those  which,  like  the  mediastinum  and 
the  diaphragm,  have  a  certain  mobility. 

The  mediastinum  is  usually  pushed  over  to  the  healthy 
side  and  the  heart  is  involved  in  this  displacement  in  a  de- 
gree depending  on  the  amount  of  the  fluid  effusion  or  the 
state  of  tension  of  the  gaseous  effusion. 

But  this  displacement  of  the  mediastinum  is  not  the  only 
phenomenon  that  is  observed.  Often,  it  is  true,  the  medias- 
tinum is  immobile,  but  sometimes  it  is  stimulated  by  rhyth- 
mic movements  which  certain  authors  have  described  as 
the  "mouvement  pendulaire"  of  the  mediastinum. 

This  movement  consists  of  an  inspiratory  displacement  of 
the  mediastinum  which  occurs  on  the  side  of  the  pneimio- 
thorax.  It  only  occurs  under  certain  conditions  which  will 
be  studied  later  on.  At  times  it  is  barely  perceptible,  at 
other  times  very  accentuated  and  apparent;  very  often  it  is 
lacking  altogether. 

The  diaphragm,  which  plays  an  important  role  in  all  that 


60  RADIO-DIAGNOSIS:  PLEURJE 

pertains  to  respiratory  phenomena,  shows  modifications  still 
more  noticeable  than  those  of  the  mediastinum.  Like  it,  it  is 
greatly  afTected,  as  much  from  the  static  as  from  the  dynamic 
point  of  view. 

Its  form  undergoes  serious  variations.  Its  convexity 
gradually  disappears;  the  muscle  flattens;  at  the  same  time 
it  is  lowered  and  presents  the  form  of  an  oblique  line  from 
top  to  bottom  and  from  within  outward.  There  results  an 
elongation  of  the  hemithorax  in  relation  to  the  opposite  side 
and  the  disappearance  of  the  costodiaphragmatic  sinus, 
which  loses  its  crescent  form. 

The  movements  are  also  markedly  modified,  and  in  a  very 
variable  manner,  according  to  the  case.  Sometimes  a  simple 
diminution  of  the  amplitude  of  the  respiratory  movements  is 
seen,  sometimes  a  retardation  of  these  movements,  some- 
times both  at  the  same  time. 

Sometimes  an  absolute  immobilization  is  noted  and  in 
certain  cases,  where  all  active  movement  has  ceased,  passive 
movements  are  seen  communicated  through  the  disturbance 
of  the  cardiac  contractions,  especially  when  the  pneumo- 
thorax occurs  on  the  left  side. 

The  coexistence  of  active  and  passive  movements  may  also 
be  observed.  The  diaphragm  continues  to  contract  in  a  cer- 
tain measure  but  it  is  more  disturbed  by  the  cardiac  beats.  In 
that  case  the  cardiac  beats  are  especially  felt  during  expira- 
tion, as  the  diaphragm  is  still  sufficiently  extended  on  inspira- 
tion to  resist  the  disturbance  from  the  cardiac  contractions. 

But  certainly  the  most  curious  phenomenon  that  one  ob- 
serves on  the  part  of  the  diaphragm  is  that  which  has  been 
described  as  the  "paradoxical  phenomenon  of  Kienbach"  or 
"movement  of  balance."  This  phenomenon  consists  in  the 
loss  of  co-ordination  of  the  contractions  in  the  two  halves  of 
the  diaphragm.  In  the  normal  state  the  diaphragm  con- 
tracts at  the  same  time  on  the  right  and  on  the  left;  the  two 
arches  are  lowered  co-ordinately  and  are  elevated  together. 
They  might  be  compared  to  two  pistons  actuated  by  the 
same  movement  in  twin  cylinders. 


PNEUMOTHORAX  61 

In  the  course  of  certain  cases  of  pneumothorax  the  disso- 
ciation of  this  movement  is  seen.  While  the  diaphragm  is 
lowered  on  the  healthy  side,  it  is  raised  on  the  side  of  the 
pneumothorax  and  inversely.  The  two  arches  act  like  the 
two  trays  of  a  balance.  They  might  be  likened  to  two 
pistons  moved  by  an  alternate  movement  in  two  paired 
cylinders. 

Several  explanations  have  been  given  for  this  phenom- 
enon.   Three  principal  theories  have  been  set  forth : 

1st:  Paralysis  of  the  diaphragm  on  the  side  affected. 

2nd:  Thoracic  aspiration. 

3rd:  Flattening  of  the  diaphragm  either  by  the  positive 
pressure  of  the  gas,  or  by  the  pressure  of  the  effusion. 

Each  one  assumes  to  give  the  sole  explanation  of  the 
phenomenon.  The  phenomenon  appears  more  complex  and 
if  much  has  been  said  of  the  diaphragm,  not  enough  has  been 
said  of  the  lung.  The  actual  practice  of  artificial  pneumo- 
thorax corresponds  to  a  true  experimental  study  of  this 
phenomenon,  the  conditions  of  the  appearance  of  which  may 
be  studied  in  detail. 

Theory  of  paralysis  of  the  diaphragm. — This  is  admitted 
by  V.  Muralt  and  Deneke  and  to  which  Beclere  agrees. 
Conforming  to  the  law  of  Stokes,  the  diaphragm  has  lost  its 
contractility  on  the  side  of  the  pneumothorax;  it  is  no  longer 
anything  more  than  an  inert  membrane  easily  affected  by 
the  differences  in  pressure.  On  inspiration  the  diaphragm  on 
the  normal  side  contracts  and  is  lowered  and  from  this  an 
increase  of  the  abdominal  tension  results  which  is  trans- 
mitted in  all  directions  and  raises  the  diaphragm  on  the 
opposite  side,  which  no  longer  offers  any  resistance. 

This  theory  is  true  in  large  part,  but  the  paralysis  of  the 
diaphragm  is  not  wholly  responsible;  it  is  only  one  of  the 
important  elements  in  the  phenomenon. 

Theory  of  thoracic  aspiration. — This  has  been  sustained 
by  Bittorf  and  by  Wellmann.  According  to  these  authors 
the  thoracic  aspiration  is  compensated  on  the  normal  side 
by  the  penetration  of  air  into  the  lung.    On  the  side  of  the 


62  RADIO-DIAGNOSIS:  PLEUR.E 

pneumothorax  the  absence  of  penetration  of  air  creates  a 
negative  pressure  which  aspirates  the  diaphragm  and  pro- 
duces its  elevation  while  it  is  lowered  on  the  normal  side. 

This  theory,  which  is  founded  on  a  sound  basis,  is  not 
opposed  to  the  preceding;  on  the  contrary,  it  adds  to  it, 
since  the  two  forces  are  acting  in  the  same  direction;  the 
first  forces  the  diaphragm  upward  while  the  other  com- 
presses it  downward ;  they  act  together  with  the  same  result. 
On  the  contrary,  this  theory,  which  has  for  its  point  of 
departure  a  negative  pressure,  seems  to  be  opposed  abso- 
lutely a  priori  to  the  following  which  has  for  its  basis  a  posi- 
tive pressure. 

Theory  of  flattening  of  the  diaphragm,  either  through  posi- 
tive pressure  of  gas  (]\Iaingot),  or  by  the  pressure  of  effusion 
(Bernard).  This  theory  is  especially  defended  by  Maingot. 
Rist  and  Bernard  identify  themselves  with  it.  It  is  open 
to  discussion.  It  is  easy  to  see  how  the  condition  is  brought 
about  in  the  course  of  artificial  pneumothorax.  Barjon 
and  P.  Courmont  have  studied  this. 

First,  it  is  quite  certain  that  there  may  be  found  in 
the  pleura  very  strong  pressures  ( -f  10  +  15  and  even 
-f  28  +  31  in  one  case)  without  there  being  any  flattening 
of  the  diaphragm;  and  that  this  complete  flattening  may 
be  seen  with  much  less  pressure  (  +  4  +  6  in  another  case). 

It  is  just  as  evident  that  the  "movement  of  balance"  is 
lacking  in  a  great  number  of  cases  of  pneumothorax  with 
very  positive  pressure.  Something  else  is  therefore  the 
cause.  Barjon  has  established  these  facts  many  times  but 
four  cases  only  of  pneumothorax  studied  with  P.  Courmont 
will  be  quoted,  indicating  the  pressure  in  the  course  of  the 
successive  interventions. 

These  four  observations  were  selected  especially  because 
they  represent  perfectly  the  different  stages  of  detachment 
and  the  increasing  progress  of  pulmonary  collapse. 


PNEUMOTHORAX 


63 


Case  I. — Detachment  very  limited.  No  balance  movement  in 
spite  of  very  positive  pressure.  Pneumothorax,  so  to  say,  does 
not  exist. 

1st.  Mrs.  Da  ...  in  the  course  of  three  successive  infla- 
tions presented  the  following  pressures : 


1.  inflation 

2.  " 

3.  " 

+    5  inspiration 

+    4 
+  10 

+    8  expiration 
+  10       " 
+  14       " 

Fig.  14.     ARTIFICIAL  PNEUMOTHORAX,  LEFT  SIDE 

Incomplete  detachment  of  the  lung.     Very  small  gaseous 
pocket  at  the  base.    No  balance. 

2nd.  Mr.  L  ...  in  the  course  of  6  successive  inflations : 


1.  inflation 

+  13^  inspiration 

+    7  expiration 

2. 

+    3 

+    7 

3.       " 

+    1 

+    2 

4.       " 

-    3 

+    3 

5.       '' 

+    4 

+    8 

6.       " 

+  28 

+  31 

Incomplete  but  rather  extensive  detachment,  occupying 
all  the  base  and  all  the  lateral  side  as  far  as  under  the  clavicle. 
Adhesion  of  the  apex.  No  balance  in  spite  of  strong  pres- 
sures. 


64 


RADIO-DIAGNOSIS:  PLEUR.^ 


Case  II. — Detachment  very  extensive  but  the  entire  apex  re- 
mains adherent;  no  balance  movement  in  spite  of  very  positive 
pressures  reaching  +  28  and  +31. 


3rd.  Mr.  Dii 


in  the  course  of  6  successive  inflations : 


1. 

inflation 

+  Yz  inspiration 

+    3  expiration 

2. 

+    3 

+    9 

3. 

+    9 

+  15 

4. 

+    9 

+  13 

5. 

+  14 

+  19 

6. 

+  11 

+  15 

Fig.  15.     ARTIFICIAL  PNEUMOTHORAX,  LEFT  SIDE 

Very  important  instantaneous  pulmonary  detachment, 
collapse  being  completed  gradually.  The  movement  of 
balance  appears  only  after  the  5th  inflation  even  though  there 
were  very  positive  pressures  from  the  3rd  and  4th  inflations. 
4th.  Mr.  C  .  .  .,  perfect  detachment;  complete  collapse 
of  the  lung,  presenting  at  the  same  time  the  movement  of 
balance  of  the  diaphragm  and  the  pendulum  movement 
of  the  mediastinum,  even  with  rather  low  pressures,  +  4 
inspiration  and  +  6  expiration  measured  before  an  inflation. 
At  this  point  the  phenomenon  is  very  much  accentuated. 
A  new  inflation  is  made  which  increases  the  pressure  to  +  12 
inspiration  and  +  15  expiration;  on  radioscopic  examination 


PNEUMOTHORAX  65 

the  movement  of  balance  and  also  the  pendulum  movement 
are  very  much  less  apparent;  the  increase  of  pressure  has 
much  diminished  their  extent. 


Fig.  16.     ARTIFICIAL  PNEUMOTHORAX,  LEFT  SIDE 

Case  III. — Progressive  total  detachment.  The  balance  move- 
ment appears  only  after  the  5th  inflation  when  pulmonary  collapse 
is  complete. 


Fi,G.  17.     ARTIFICIAL  PNEUMOTHORAX,  RIGHT  SIDE 

Case  IV. — Complete  detachment  and  total  pulmonary  collapse. 
The  balance  movement  exists  with  low  positive  pressures  +4+6; 
it  diminishes  with  higher  pressures  +  12  +  15. 


66  RADIO-DIAGNOSIS:  PLEUR.E 

Examination  of  these  four  cases  shows  that  very  often 
the  phenomenon  of  balance  is  lacking  even  with  very  positive 
pressures  of  +  28  and  +  31  in  Case  2.  Case  3  alone  would 
seem  favorable  to  the  influence  of  pressure  since  the  phe- 
nomenon is  seen  to  appear  after  the  5th  inflation  when  the 
pressure  attains  its  maximum,  but  it  is  also  at  this  point 
that  the  pulmonary  collapse  is  complete;  and  before  it  was 
sufficiently  advanced  even  with  very  positive  pressures  of 
+  9  and  +  15,  the  movement  of  balance  did  not  exist.  How- 
ever, Case  4  would  tend  to  demonstrate  the  contrary  since 
the  phenomenon  is  observed  at  a  maximum  with  a  low 
pressure,  +4  +  6,  and  since  it  diminishes  perceptibly  with 
a  higher  pressure,  +  12  +  15.  It  might  be  said,  therefore, 
that  in  this  case  the  phenomenon  is  observed  in  spite  of  a 
high  pressure.  In  spontaneous  pneumothorax  the  pressures 
are  always  much  lower  and  yet  under  these  conditions 
marked  movements  of  balance  are  always  found.  It  is  not 
necessary  therefore  to  have  a  high  pressure  to  produce 
them.* 

In  pneumothorax  accompanied  by  effusion  it  is  a  ques- 
tion whether  the  weight  of  the  effusion  could  replace  the 
tension  of  the  gas  by  acting  directly  on  the  diaphragm. 
Some  investigators  have  thought  so. 

The  observation  demonstrates  that  if  the  movement  of 
balance  exists  in  pneumothorax  with  slight  effusion,  it  is 
scarcely  ever  found  with  large  effusion,  which,  however, 
acts  on  the  diaphragm  with  considerable  pressure. 

It  seems  therefore  that  it  might  be  said  that  the  move- 
ment of  balance  of  the  diaphragm  may  be  observed  in  spite 

*  Barjon  examined,  through  courtesy  of  Dr.  Dumarest,  a  series  of  fourteen 
cases  of  pneumothorax  at  the  Mangini  Sanatorium.  All  these  cases  had 
positive  pressure;  the  balance  movement,  however,  was  found  in  only  one- 
half  the  cases.  The  case  which  had  at  the  same  time  the  balance  movement 
and  the  pendulum  movement  most  marked,  had  only  a  medium  pressure  of 
+  4. 

With  P.  Courmont,  Barjon  saw  a  splendid  balance  movement  in  a  woman 
where  pressure  reached  only  —  6+2  and  in  forced  inspiration  fell  to  • —  6 
+  0. 


PNEUMOTHORAX  67 

of  a  slight  effusion,  but  a  large  effusion  rather  prevents  it 
from  being  produced. 

Does  the  pressure  signify  anything?  What  role  has  it 
in  the  production  of  the  phenomenon? 

The  role  of  pressure  has  a  certain  value,  but  it  does  not 
act  except  when  combined  with  other  necessary  conditions; 
it  is  not  even  necessary  that  the  pressure  be  very  high.  A 
pressure  although  very  high  is  not  sufficient  alone  to  stimu- 
late the  paradoxical  movement  of  the  diaphragm  if  the 
other  conditions  are  not  fulfilled. 

The  mechanism  of  the  movement  of  balance  appears 
therefore  as  rather  complex  and  this  would  explain  its  rela- 
tive rarity  in  pneumothorax.  It  is  often  lacking,  in  fact, 
and  Bar j  on  estimates  that  it  is  only  met  with  in  about  40 
out  of  100  cases. 

This  phenomenon  would  seem  to  result  from  a  kind  of 
unstable  equilibrium  established  on  both  sides  of  an  inert 
floating  membrane,  very  sensitive  to  the  slightest  varia- 
tions— the  diaphragm  in  this  particular  case. 

Bar  j  on  believes  that  the  same  conditions  might  be  ap- 
plied to  the  mediastinum  and  might  serve  to  explain  also 
the  inspiratory  pendulum  movement  which  is  not  more 
frequent  than  the  movement  of  balance  and  which  often 
coexists  with  it,  which  seems  to  indicate  that  they  obey 
very  much  the  same  laws. 

The  first  condition  to  be  realized  therefore  is  the  inertia 
and  the  absolute  freedom  of  the  diaphragm. 

The  inertia  is  obtained  by  the  muscular  paralysis  con- 
forming to  the  law  of  Stokes  under  the  influence  of  the 
irritation  provoked  by  the  penetration  of  gas  into  the  pleura, 
but  also,  and  especially,  by  the  gradual  suppression  of  the 
respiratory  function  of  the  lung  under  the  influence  of  its 
progressive  collapse.  The  diaphragmatic  respiration  is 
effected  by  a  reflex  stimulated  by  the  lung.  While  the  lung 
remains  in  contact  with  the  diaphragm,  the  reflex  functions 
normally,  owing  to  the  stimulation  by  the  lung.  "WTien 
the  contact  becomes  less  extensive  and  less  perfect,  the 


68  RADIO-DIAGNOSIS:  PLEURA 

reflex  diminishes;  it  ceases  when  the  separation  has  become 
complete.  There  is  no  doubt  that  this  is  one  of  the  principal 
factors  in  inertia  of  the  diaphragm. 

The  freedom  of  the  diaphragm  is  dependent  on  the  total 
absence  of.  adhesions;  in  fact,  the  movement  of  balance  is 
never  produced  with  an  adherent  diaphragm. 

The  forces  which  act  on  a  diaphragm  in  this  condition 
are  of  two  kinds  and  are  as  follows:  abdominal  pressure 
which  forces  it  downward,  and  thoracic  aspiration  which 
draws  it  upward.  There  is  nothing  to  be  said  as  to  ab- 
dominal pressure,  it  explains  itself.  It  is  the  inspiratory 
lowering  of  the  opposite  diaphragm  which  breaks  the  equi- 
librium and  raises  the  other  side  of  the  diaphragm  which 
has  become  inert. 

This  thoracic  aspiration  is  the  result  of  the  inspiratory 
increase  in  the  diameters  of  the  thorax.  On  the  normal 
side  this  force  is  compensated  for  by  the  entrance  of  air 
into  the  lung.  On  the  side  of  the  pneumothorax,  the  res- 
piration being  suppressed  and  no  air  being  admitted  to  the 
empty  space,  aspiration  acts  on  the  walls,  particularly  on 
the  diaphragm  and  on  the  mediastinum,  which  are  drawn 
in.  The  principal  condition  of  thoracic  aspiration  is  there- 
fore the  suppression  of  the  respiratory  function  of  the 
lungs. 

This  implies  the  complete  collapse  of  the  lung.  When 
adhesions  keep  an  important  portion  of  the  lung  stretched, 
it  does  not  collapse,  inspiration  persists ;  the  thoracic  aspira- 
tion is  diminished  or  suppressed.  This  explains  why  the 
movement  of  balance  is  never  found  in  incomplete  pneumo- 
thorax even  when  the  adhesions  are  limited  to  the  region  of 
the  apex  and  when  the  diaphragm  is  not  involved.  In  this 
case  even  a  very  high  pressure  never  suppresses  the  pul- 
monary respiration  and  the  movement  of  balance  does  not 
appear.  This  shows  the  importance  of  the  part  of  the  lungs 
in  producing  this  phenomenon. 

If  the  lung  is  not  adherent,  if  it  is  retracted  towards  the 
hilus,  then  the  part  of  pressure  appears,  which  must  main- 


PNEUMOTHORAX  69 

tain  the  pulmonary  collapse  and  prevent  the  air  from  pene- 
trating. It  is  only  necessary  that  the  pressure  remain  some- 
what high,  provided,  however,  that  it  is  always  higher  than, 
or  equal  to,  the  atmospheric  pressure.  Too  high  a  pressure 
under  these  conditions  would  only  diminish  or  hinder  the 
movement  of  balance,  on  the  one  hand,  by  diminishing  the 
thoracic  aspiration,  on  the  other  hand,  by  opposing  the  up- 
ward movement  of  the  diaphragm.  This  is  what  was  noted 
in  Case  4.  But  under  the  same  conditions  a  negative  pres- 
sure, by  diminishing  the  pulmonary  collapse,  opposes  the 
production  of  the  movement.  In  this  sense  it  might  be  said 
that  an  additional  inflation,  by  transforming  the  negative 
into  a  positive  pressure  would  cause  the  phenomenon  to 
reappear. 

The  essential  conditions  for  the  production  of  the  phenom- 
enon of  balance  might  therefore  be  stated  thus:  absolute 
inertia  of  the  diaphragm  with  absence  of  all  adhesions;  as 
complete  suppression  as  possible  of  the  respiratory  function 
of  the  lungs,  brought  about  by  its  total  collapse;  the  main- 
tenance of  a  moderate  positive  pressure. 

By  replacing  in  the  above  statement  the  word  ''dia- 
phragm" with  the  word  ''mediastinum,"  we  shall  find  the 
essential  conditions  which  are  present  in  producing  the 
inspiratory  pendulum  movement.  Inertia  of  the  mediasti- 
num and  absence  of  adhesions  are  equally  necessary;  the 
pressure  on  the  mediastinum  is  brought  about  by  the  pene- 
tration of  air  into  the  normal  lung,  its  traction  by  the 
thoracic  aspiration  on  the  opposite  side. 

If  only  one  of  these  conditions  is  lacking,  the  phenomenon 
is  not  produced  and  that  explains  its  absence  in  so  great  a 
number  of  cases  of  pneumothorax. 

In  complete  and  absolute  pneumothorax  the  two  phenom- 
ena may  be  seen  at  the  same  time:  movement  of  balance  of 
the  diaphragm  and  inspiratory  pendulum  movement  of  the 
mediastinum.  Sometimes  they  are  dissociated.  Barjon  has 
seen  a  case  of  pneumothorax  with  slight  effusion  show  a  fine 
movement  of  balance;  the  pendulum  movement  was  lacking 


70  RADIQ-DLVGNOSIS:  PLEUR.E 

on  account  of  some  adhesions  which  immobilized  the  me- 
diastinum. Inversely,  in  a  patient  in  whom  the  apex  was 
completely  detached,  there  was  seen  a  very  good  and  limited 
pendulum  movement  in  the  superior  mediastinum,  some 
adhesions  towards  the  base  immobilizing  at  the  time  the 
inferior  portion  of  the  mediastinum  and  the  diaphragm. 
Very  often  neither  one  of  these  movements  is  observed. 

In  sununing  up,  the  images  which  appear  on  the  screen  in 
the  study  of  pneumothorax  show  a  characteristic  appearance 
not  found  in  any  other  thoracic  affection. 

The  radioscopic  examination  is  therefore  very  charac- 
teristic and  plays  a  most  important  role  in  the  study  of 
pneumothorax.  This  examination  is  indispensable  in  making 
diagnosis.  It  is  limited  to  confirming  it  when  the  affection 
has  already  been  diagnosed  by  the  clinician,  who  has  deter- 
mined the  usual  stethoscopic  signs  of  pneumothorax  by 
examination  of  the  patient:  amphoric  breathing,  metallic 
tinkling,  brassy  sounds,  Hippocratic  succession,  etc.  But 
the  extent  of  the  pneumothorax  and  especially  the  condition 
of  the  lung  are  better  determined  by  radiological  examina- 
tion than  b}^  auscultation. 

On  the  other  hand,  the  so-called  silent  cases  of  pneumo- 
thorax are  no  longer  considered,  and  the  complete  absence  of 
all  positive  signs  on  auscultation  makes  them  impossible  to 
detect  except  by  radioscopic  examination,  which  alone  is 
capable  of  demonstrating  them. 

Limited  or  encysted  pneumothorax. — This  type  of  pneumo- 
thorax is  produced  in  a  pleura  divided  off  by  adhesions  and 
involves  onlj^  a  limited  part  of  the  pleura.  It  may  be  of 
pulmonary  origin  in  certain  tuberculous  cases;  it  may  be  of 
pleural  origin  when  it  follows  an  encysted  pleurisy — an 
interlobar  pleurisy,  for  example. 

Since  it  is  much  more  limited  than  total  pneumothorax,  it 
is  more  silent  from  the  clinical  point  of  view  and  very  often 
shows  no  sign.  Radioscopic  examination  alone  indicates  its 
presence.  Ordinarily  it  is  seen  on  the  screen  as  a  limited 
hydroseric  image,  with  the  surface  of  the  fluid  level  mobile 


PNEUMOTHORAX  71 

and  changing.  Hippocratic  succussion  exists  when  the 
quantity  of  fluid  is  sufficient,  but  the  greater  number  of  the 
other  signs  already  described  are  lacking:  the  cavity  being 
most  often  connected  neither  with  the  diaphragm  nor  the 
mediastinum,  the  necessary  conditions  for  producing  the 
movement  of  balance  and  the  pendulum  movement  are  com- 
pletely lacking.  The  image  is,  however,  sufficiently  char- 
acteristic to  attract  attention. 

Bar j  on  had  occasion  to  follow  for  several  weeks  a  patient 
with  partial  pneumothorax  that  never  gave  any  stethoscopic 
sign.  He  watched  its  progressive  retrogression,  its  disap- 
pearance and  definite  cure  without  intervention. 

Diagnosis  is  sometimes  difficult  in  the  case  of  a  pulmonary 
cavity  when  it  presents  rather  large  dimensions  and  con- 
tains a  certain  quantity  of  fluid.  Barjon  had  a  tuberculous 
case  in  whom  the  radioscopic  image  suggested  a  partial 
pneumothorax,  but  autopsy  showed  a  large  cavity.  In  such 
cases  there  is  no  certain  indication  for  making  diagnosis. 
When  cavities  are  smaller,  they  are  often  multiple;  they  con- 
tain only  a  little  fluid;  often  in  a  very  intermittent  manner, 
they  empty  and  fill  from  day  to  day;  their  edges  are  more 
opaque,  the  surrounding  pulmonary  tissue  being  more  con- 
densed, but  when  they  show  these  characteristics,  they 
scarcely  ever  are  confused  with  a  limited  pneumothorax. 

In  another  case  (although  rare)  Barjon  observed  with 
P.  Courmont  a  thoracic  hernia  of  the  stomach  through  the 
diaphragm.  The  diagnosis  was  complicated  by  the  intra- 
thoracic stomach  being  perforated  at  the  site  of  an  old  ulcer 
and  this  perforation  had  brought  about  the  development  of  a 
true  pyopneumothorax  of  the  large  cavity.  There  were, 
therefore,  two  superimposed  hydroseric  cavities.  The 
inferior  one  was  the  herniated  stomach  which  had  become 
thoracic  with  its  fluid  contents,  its  air  chamber,  its  mobile 
fluid  level;  the  superior  was  the  true  pyopneumothorax  of 
the  large  cavity.  It  gave  the  illusion  of  a  double  pneumo- 
thorax, the  inferior  appearing  partial  and  the  superior  total. 
Autopsy  gave  the  explanation  of  this  curious  picture. 


72  RADIO-DUGNOSIS:  PLEURA 

Double  pneumothorax. — Cases  of  this  type  may  be  com- 
pared with  certain  radioscopic  images  of  pneumothorax  with 
fluid  effusion  showing  the  presence  of  two  lines  of  fluid  level 
distinct  and  superimposed. 

This  particular  appearance  is  explained  in  the  following 
way.  It  is  a  pneumothorax  developed  in  a  pleural  cavity 
showing  some  adhesions  or  slight  diverticula  above  the 
level  of  the  effusion.  When  the  patient  lies  in  the  dorsal, 
ventral,  or  lateral  decubitus,  a  small  amount  of  fluid  may 


Fig.  18.  THORACIC  HERNIA  OF  THE  STOMACH,  GASTRIC  PERFORA- 
TION, SECONDARY  DEVELOPMENT  OF  A  PYOPNEUMOTHORAX 
OF  THE  LARGE  CAVITY 

filter  towards  these  adhesions  and  penetrate  the  diverticula. 
If  the  patient  is  raised  up  quickly,  the  fluid  may  be  retained 
in  these  diverticula,  where  it  forms  small  pool-like  areas 
with  a  movable  level  of  fluid,  which  give  the  appearance 
of  a  second  independent  pneumothorax. 

Artificial  Pneumothorax. — Radiological  examination 
is  indispensable  in  artificial  pneumothorax.  Without  it 
this  method  of  treatment  would  be  practically  inapplicable. 

Introduced  into  practice  by  Forlanini,  this  new  therapeu- 
tic measure  met  with  success  and  unfortunately  with  some 
serious  results  which  awoke  the  instinctive  distrust  of  phy- 


PNEUMOTHORAX  73 

sicians.  It  was  necessary  to  make  it  more  exact  regarding 
indications  and  contra-indications,  more  careful  in  inter- 
vention, and  more  reserved  in  after  treatment. 

The  physician  proposing  intervention  by  artificial  pneu- 
mothorax in  a  tuberculous  patient  will  ask  the  radiologist 
two  principal  questions:  1.  Is  pneumothorax  indicated? 
2.  Is  it  possible? 

The  indications  or  contra-indications  for  intervention 
are  obtained  clinically  and  from  the  development  of  the 
pulmonary  lesion,  the  general  condition  of  the  patient,  the 
functioning  of  the  cardio-vascular  system,  the  presence  or 
absence  of  all  other  tuberculous  manifestation.  All  this 
becomes  part  of  the  clinical  examination. 

But  there  is  another  point  of  extreme  importance  on 
which  the  radiologist  must  give  advice: — the  extent  of  the 
lesions,  whether  they  are  unilateral  or  bilateral. 

The  unilateral  occurrence  of  lesions  has  been  rightly 
considered  a  very  important  condition.  It  is  evident  that 
the  one  lung  which  remains  in  a  functioning  condition  must 
be  capable  of  hematosis.  Radioscopic  examination  is  there- 
fore very  important  because  it  indicates  the  condition  of 
transparency  of  the  lung.  To  be  of  the  greatest  value  the 
clinical  and  radioscopic  examinations  must  be  in  accord. 
If  auscultation  is  negative  and  the  screen  indicates  a  normal 
transparency  of  the  lung,  it  may  be  concluded  that  inter- 
vention is  possible.  If  the  radioscope  shows  abnormal 
shadows  which  are  added  to  evident  stethoscopic  signs,  the 
contra-indication  is  decisive. 

If  there  is  a  disagreement  between  the  two  methods  of 
diagnosis,  the  case  must  be  discussed.  1st  case.  The  radio- 
scope  shows  a  clear  lung  but  auscultation  reveals  the  exist- 
ence of  signs  by  no  means  doubtful;  an  early  lesion  may  be 
suspected,  still  very  questionable  but  with  a  progressive 
tendency;  it  is  a  question  whether  intervention,  by  stimulat- 
ing the  functioning  of  the  lung  may  not  aggravate  the  lesions 
and  make  the  condition  worse.  It  is  preferable  not  to  at- 
tempt it. 

2d  case.  The  radioscope  shows  one  or  several  abnormal 


74  RADIO-DIAGNOSIS:  PLEUR.E 

shadows  but  careful  auscultation  of  these  areas  does  not 
reveal  any  suspicious  sound ;  it  may  be  old  cicatrized  lesions 
without  any  progressive  tendenc}^  which  are  not  a  contra- 
indication to  pneumothorax. 

In  all  patients  in  whom  there  is  a  question  of  interven- 
tion by  artificial  pneumothorax,  careful  radioscopy  is  in- 
dispensable. 

The  second  question,  whether  pneumothorax  is  possible, 
is  more  difficult.  In  the  first  case  the  question  concerns 
the  lung;  in  the  second,  the  pleura. 

Nothing  is  more  difficult  clinically  than  to  know  whether 
or  not  there  are  pleuro-pulmonary  adhesions;  and  to  recog- 
nize their  topography,  their  extent,  their  firmness.  It  may 
be  claimed  that  exploration  of  the  thorax  by  the  usual 
means:  palpation,  percussion,  auscultation  cannot  always 
furnish  exact  information  in  this  respect.  Radioscopic 
examination  has  been  much  depended  on  to  complete  this. 
It  must  be  acknowledged  that  it  has  done  this  only  in  a 
slight  measure.  Without  doubt  it  gives  better  results  than 
those  obtained  clinically;  at  least,  it  gives  probable  signs, 
if  it  does  not  give  certainty. 

Radioscopic  examination  is,  however,  indispensable  from 
this  point  of  view.  By  showing  the  topography  of  the 
pulmonary  lesions,  it  furnishes  indications  of  the  probable 
location  of  the  points  of  adhesion  and  their  extent.  It  gives 
information  on  the  condition  of  the  base,  on  the  appear- 
ance of  the  costodiaphragmatic  sinus,  in  the  vicinity  of 
which  the  puncture  is  usually  made,  and  on  the  extent  of 
the  respiratory  excursion  of  the  diaphragm  and  the  mobility 
of  its  movements. 

When  the  costodiaphragmatic  sinus  has  retained  its 
crescent  form,  when  it  has  kept  all  its  depth  and  trans- 
parency, when,  at  the  same  time,  the  diaphragm  has  lost 
neither  the  regularity  of  its  contour  or  mobility,  when  the 
amplitude  of  its  displacement  has  not  been  at  all  diminished, 
it  is  almost  certain  that  there  are  no  pleural  adhesions,  at 
least  in  the  diaphragmatic  region. 


PNEUMOTHORAX  75 

Inversely,  complete  effacement  of  the  sinus  with  total 
obscurity  of  its  inferior  angle,  disappearance  of  the  contour 
of  the  diaphragmatic  arch  with  immobilization,  suppression 
of  the  respiratory  movements  indicate  almost  certainly  the 
existence  of  a  symphysis  of  the  diaphragmatic  pleura. 

But  between  these  two  extreme  aspects,  a  whole  series 
of  intermediary  images  exists,  the  significance  of  which  is 
much  less  definite. 

Usually  when  a  reduction  of  the  depth  of  the  sinus  is 
established,  a  deformation  of  the  diaphragmatic  curve  and 
an  appreciable  diminution  in  the  extent  of  the  respiratory 
movements,  the  probability  is  that  adhesions  exist,  some- 
times slight,  sometimes  firm  and  extensive  although  the 
base  has  retained  all  its  clearness. 

In  other  cases  even  with  a  very  noticeable  obscurity 
added  to  the  preceding  signs,  no  adhesions  are  present  and 
the  pneumothorax  will  be  perfectly  successful. 

It  ought  to  be  understood  that  a  purely  pulmonary  process, 
if  sufficiently  extensive,  is  enough  in  itself  to  obscure  the 
base,  to  diminish  the  respiratory  movements  of  the  dia- 
phragm almost  to  suppression,  to  reduce  in  large  measure 
the  extent  of  the  costodiaphragmatic  sinus  and  all  this 
without  there  being  any  adhesions. 

Experience  shows  that  in  certain  cases  pulmonary  de- 
tachment is  very  good  although  the  radioscopic  picture 
suggested  the  existence  of  adhesions;  while  in  other  cases 
where  cure  has  been  confidently  undertaken,  it  is  impossible 
to  obtain  a  result  on  account  of  the  existence  of  very  ex- 
tensive adhesions  which  on  examination  were  not  suspected. 
It  is  therefore  impossible  to  make  an  absolute  statement. 

After  an  attempt  at  artificial  pneumothorax  another 
careful  radioscopic  examination  should  be  made  which  will 
then  give  definite  information.  It  will  show  immediately 
whether  the  attempt  has  been  successful  or  not  and  the 
operator  will  know  very  quickly  whether  he  ought  to  follow 
up  this  treatment  or  abandon  it. 

Radioscopic   examination   during   treatment — When    arti- 


76  RADIO-DLVGNOSIS:  PLEUR.E 

jficial  pneumothorax  has  been  undertaken,  it  is  necessary 
to  make  a  number  of  radioscopic  examinations  before  and 
after  each  additional  inflation  and  even  in  the  interval  if 
it  is  possible. 

Inmiediately  after  the  first  inflation  the  patient  ought 
to  be  examined,  and  this  examination  is  the  most  important 
of  all  because  it  gives  at  once  a  general  idea  of  what  may  be 
expected. 

When  after  the  first  inflation  an  important  detachment 
is  seen  and  a  large  air  chamber  is  produced,  this  may  be 
considered  a  good  sign  for  favorable  prognosis.  It  is  prob- 
able that  the  detachment  will  be  completed  gradually 
during  successive  interventions  and  finally  a  more  or  less 
complete  collapse  of  the  lung  will  be  obtained. 

On  the  other  hand,  when  the  first  inflation  has  not  pro- 
duced any  detachment,  when  no  accumulated  air  chamber 
is  found,  but  only  some  diffuse  pool-like  areas,  or  even  an 
obscurity  as  extensive  as  before,  one  may  fear  a  bad  prog- 
nosis. There  are  certainly  diffuse,  extensive  adhesions  which 
will  prevent  all  important  detachment  and  the  pneumothorax 
is  certain  to  fail.  The  careful  operator  will  stop  after  this 
attempt,  the  more  persistent  will  again  attempt  one  or  two 
additional  inflations,  but  usually  they  will  have  a  good  deal 
of  difficulty  in  the  second  attempt,  still  more  in  the  third, 
and  finally  will  be  obliged  to  stop. 

This  is  the  most  important  part  of  radioscopic  examination, 
namely,  the  selection  of  cases  which  ought  to  be  followed  up 
and  those  which  ought  to  be  abandoned. 

No  other  method  of  examination  for  selection  of  cases  is 
as  decisive.  There  is  often  an  illusion  of  success;  often  into 
the  adherent  pleura  large  quantities  of  nitrogen  gas  are 
passed  without  effort  or  excessive  pressure,  500  to  1000  cubic 
centimeters  (Barjon  has  even  seen  2  liters  used  in  one  case). 
Radioscopic  examination  alone  can  show  that  there  was  no 
such  extensive  detachment  as  was  thought. 

It  is  a  question  in  these  cases  of  what  becomes  of  these 
large  quantities  of  nitrogen  gas.    It  is  probable  that  it  filters 


PNEUMOTHORAX  77 

through  a  loose  net-work  of  adhesions  as  if  through  the 
meshes  of  a  large  net,  and  that  it  is  rapidly  absorbed,  for  the 
pressure  drops  quite  rapidly  in  these  cases.  In  all  cases  ex- 
tensive and  persistent  detachment  is  not  produced.  If  the 
bubbles  of  gas,  passing  through  the  meshes,  detach  them 
temporarily,  these  adhesions  apparently  become  speedily 
adherent  again  and  still  more  firmly,  as  if  under  the  influence 
of  a  local  reaction,  which  explains  why  the  subsequent  at- 
tempts become  more  and  more  difficult  (P.  Courmont). 

When  pneumothorax  appears  indicated,  the  attempt  should 
be  carefully  made  and  radioscopic  examination  seems  the 
best  way  to  secure  information,  for  it  indicates  at  once  the 
process  which  it  is  best  to  follow. 

In  cases  where  pneumothorax  is  at  once  sufficiently  suc- 
cessful to  merit  its  being  continued,  radioscopic  examination 
will  follow  its  progress.  The  adhesions  which  had  resisted 
the  first  inflations  will  gradually  be  seen  to  give  way  and 
pulmonary  collapse  will  be  complete.  The  best  results  can 
be  hoped  for  in  these  cases. 

The  lung  is  reduced  to  a  narrow  median  band;  all  respira- 
tion is  suppressed;  the  organ  is  completely  passive. 

The  thorax  is  uniformly  clear;  its  dimensions  are  increased 
through  the  lowering  of  the  diaphragm;  the  displacement  of 
the  heart  and  mediastinum  is  at  times  considerable. 

The  heart  is  stimulated  by  rapid  pulsations  which  are 
communicated  in  a  certain  degree  to  the  diaphragm  and 
mediastinum  and  these,  on  the  other  hand,  are  also  stimu- 
lated by  the  particular  movements  already  studied — the 
inspiratory  pendulum  movement  of  the  mediastinum,  para- 
doxical movement  of  the  diaphragm.  This  is  seen  in  total 
and  complete  pneumothorax. 

But  often  the  result  is  less  satisfactory.  The  detachment, 
although  extensive,  is  not  complete;  an  important  portion 
of  the  lung  remains  adherent,  sometimes  the  entire  apex, 
sometimes  a  part  of  the  base,  or  again,  the  middle  portion 
between  the  two  air  chambers,  one  superior,  the  other 
inferior. 


78  RADIO-DL\GNOSIS:  PLEUR.E 

These  are  the  cases  of  incomplete  pneumothorax  in  which 
the  radioscope  alone  can  furnish  any  information  as  to  their 
form.  The  results  are  less  striking  and  less  satisfactory,  but 
in  these  cases  of  incomplete  pneumothorax  radioscopy  would 
not  be  valueless,  however,  and  in  a  certain  number  of  cases 
would  have  a  beneficial  effect  by  observing  the  development 
of  the  disease  (Dumarest). 

i\Iany  patients  in  the  course  of  treatment  have  complica- 
tions which  can  be  followed  by  the  radioscope.  They  consist 
of  congestive  attacks  on  the  opposite  side  where  the  lung 
showed  in  reality  more  serious  lesions  than  those  suspected. 
They  consist  especially  of  pleural  effusions  on  the  side  of  the 
pneumothorax;  either  infection  has  occurred  during  an  inter- 
vention (lung  puncture,  lack  of  asepsis),  or  an  autoinfection 
of  the  pleura  has  been  brought  about  through  a  series  of 
pre-existing  superficial  subpleural  lesions.  These  effusions, 
at  first  serofibrinous  often  become  purulent.  It  is  important 
to  follow  their  development — their  increase  and  retrogres- 
sion— to  find  a  possible  indication  for  puncture. 

All  of  these  divers  occurrences  lower  the  percentage  of 
favorable  results  in  the  few  cases  of  pneumothorax  which 
have  been  done.  It  is,  therefore,  necessary  to  be  very  cau- 
tious in  passing  judgment  on  a  method  where  definite  good 
results  are  still  the  exception. 

In  summing  up,  radiological  examination  applied  to  the 
study  of  artificial  pneumothorax  is  very  important.  It  as- 
sists in  determining  the  indications  and  contra-indications 
for  this  method,  which  on  the  whole  is  applicable  only  to  a 
very  limited  number  of  tuberculous  cases,  especially  in  hos- 
pital centers  where  patients  enter  in  an  advanced  state. 
Bernard  and  Laennec  in  628  patients  found  indications  only 
22  times  and  in  only  6  was  the  pneumothorax  successful  and 
continued,  making  a  little  less  than  one  per  cent. 

The  main  function  of  the  radioscope,  once  the  treatment 
has  been  undertaken,  consists  in  pointing  out  the  favorable 
cases  which  ought  to  be  followed  up  and  the  unfavorable 
ones  where  extensive  adhesions  are  bound  to  cause  failure. 


PART  III 
RADIOLOGICAL  STUDY  OF  THE  BRONCHI 


CHAPTER  I 
FOREIGN  BODIES  IN  THE  BRONCHI 

THE  entrance  into  the  bronchi  of  foreign  bodies  of 
small  size  is  rather  frequent.  It  is  very  important 
to  be  able  to  determine  their  presence,  to  mark  their  exact 
location,  for  in  spite  of  the  apparent  toleration  of  the  bron- 
chial tubes,  there  is  some  danger  in  letting  them  remain  too 
long. 

Two  methods  of  exploration  are  at  the  physician's  disposal : 
bronchoscopy  and  radioscopy.  Both  are  complete  and  very 
well  tried  out  and  it  is  interesting  to  use  them  together. 

Radioscopic  examination  being  more  simple  and  less  pain- 
ful ought  to  be  made  first;  it  furnishes  general  information 
which  may  be  of  use  later  in  bronchoscopic  examination. 

Nature  of  foreign  bodies. — Foreign  bodies  may  vary  greatly 
and  it  is  impossible  to  foresee  all  those  which  may  by  chance 
get  into  the  bronchi.  Radiologically  they  may  be  divided 
into  two  main  classes:  metallic  and  non-metallic  bodies,  the 
first  being  ordinarily  quite  easy  to  see,  the  second  remaining 
often  invisible.  To  the  first  class  belong  pins,  which  are  by 
far  the  most  conmion. 

Bar j on  has  also  found  a  piece  of  a  metal  hook,  a  copper 
eyelet,  a  mouthpiece  of  a  trumpet,  a  small  tip  of  a  tracheot- 
omy tube.    Garel  has  seen  a  cuff  button  and  a  nail. 

Among  the  second  class,  food  particles  especially  are 
found.  In  one  case  of  Barjon's  it  was  a  pea.  These  foreign 
bodies  are  absolutely  invisible  on  radioscopic  examination 
and  bronchoscopy  must  be  employed  in  such  a  case  and 
always  when  fluoroscopic  examination  is  negative. 

Between  these  two  classes  of  foreign  bodies,  there  are 
also  found  fragments  of  bone  which  sometimes  may  be 
visible  but  which  very  often  are  not,  as  usually  the  frag- 

81 


82  RADIO-DIAGNOSIS:  PLEURAE 

ments  are  very  small  and  thin.  DeBannes  has  published 
an  interesting  case  of  this  kind  in  which  the  foreign  body- 
had  caused  a  small  suppurative  focus. 

Location  of  foreign  bodies. — ]\Iost  often  foreign  bodies 
lodge  in  the  right  bronchus.  The  right  bronchus  is  wider 
than  the  left,  has  a  more  vertical  direction  and  is  a  more 
direct  continuation  of  the  trachea.  At  times  they  pene- 
trate rather  far  as  in  the  case  of  Barjon's  where  it  reached 
the  third  bifurcation  of  the  bronchus,  as  was  confirmed  by 
bronchoscopy.  Sometimes,  however,  they  enter  the  left 
bronchus  and  become  fixed. 

Visibility. — Metallic  bodies  are  very  clearly  visible,  espe- 
cially if  they  are  rather  thick  as  pieces  of  tube  or  a  mouth- 
piece of  a  trumpet.  A  pin  is  less  visible  and  the  image  must 
be  carefully  studied. 

In  the  frontal  examination  (which  is  the  preferable  posi- 
tion for  this  study),  it  will  be  found  on  the  edge  of  the 
median  shadow  and  extending  a  little  way  beyond.  If  it 
is  a  glass-headed  pin,  the  head  and  the  shank  are  quite 
easily  distinguished;  the  head  usually  points  downward, 
the  point  upward. 

To  see  well  one  should  have  absolute  darkness  and  be- 
come accustomed  to  it  for  a  long  time;  the  patient  must  be 
completely  immobilized  and  a  diaphragm  should  be  used 
to  examine  in  detail  the  hilus  region  on  both  sides.  When 
the  body  foreign  has  been  discovered,  a  new  examination 
should  be  made  in  the  dorsal  position  and  also  in  the  dif- 
ferent oblique  positions  and  an  attempt  should  be  made 
to  locate  it  again.  In  this  way  its  presence  will  be  con- 
firmed and  all  that  remains  to  do  is  to  make  a  radiograph 
in  the  position  which  has  appeared  most  favorable,  usually 
the  frontal  position. 

Mobility. — When  foreign  bodies  have  remained  a  certain 
time  in  the  bronchi  they  become  fixed,  embedded  and 
covered  by  the  ulcerated  mucous  membrane.  In  the  be- 
ginning, during  the  first  days  after  penetration,  the  foreign 
bodies  are  often  entirely  mobile.     An  attack  of  coughing 


Radiograph  12.     METALLIC    MOUTHPIECE   OF  A   TRUMPET   IN   THE 
RIGHT  BRONCHUS 
The  foreign  body  stands  out  clearlj-  in  the  right  bronchus  between  the  shadow 
of  the  hilus  and  that  of  the  right  auricle. 


Radiograph  13.  GLASS  HEADED  STEEL  PIN  IN  THE  LEFT  BRONCHUS 
The  pin  is  lodged  in  the  left  bronchus.  Image  is  found  located  between  the 
fifth  and  sixth  ribs,  posteriorly;  the  head  below  at  the  sixth  rib.  the  point  upward 
at  the  insertion  of  the  fifth.  The  shadows  of  the  base  of  the  heart  and  the  pul- 
monary artery  cover  the  foreign  body  and  make  it  less  visible. 


FOREIGN  BODIES  IN  THE  BRONCHI  83 

is  enough  to  displace  them  and  consequently  attempts  at 
bronchoscopic  examination  not  followed  by  extraction 
make  them  extremely  mobilizable.  Bar j  on  has  seen  a  glass- 
headed  steel  pin  which  he  located  in  the  right  bronchus 
pass  into  the  left  bronchus,  where  it  was  found  again  by 
Arcelin  some  days  afterwards,  and  again  pass  back  into 
the  right  bronchus.  He  also  saw  another  pin  and  a  mouth- 
piece of  a  trumpet  which  were  mobilized  in  such  a  way  after 
bronchoscopy  that  they  were  brought  up  as  far  as  the 
pharynx  where  they  were  swallowed  and  finally  eliminated 
in  the  natural  way. 

Bronchoscopy  ought  therefore  always  to  be  tried,  for  if 
the  first  attempt  at  extraction  does  not  succeed,  it  may  at 
times  cause  sufficient  mobilization  to  produce  a  natural 
expulsion  of  the  foreign  body. 

Tolerance  and  infection. — The  bronchi  appear  rather 
tolerant  to  foreign  bodies.  At  the  time  of  entrance  there 
is  usually  produced  a  very  acute  reaction,  fit  of  coughing 
and  suffocation.  But  this  soon  quiets  down  and  no  func- 
tional disturbance  is  manifest. 

Zimmern,  Tuchini  and  Bernard,  and  later  Chilaiditi  have 
demonstrated  that  a  very  large  amount  of  bismuth  paste 
might  accidentally  enter  the  bronchi  without  any  great 
harm.  Yet  under  similar  circumstances  a  patient  of  Des- 
ternes  died  immediately  from  asphyxia. 

In  fact,  too  much  confidence  must  not  be  placed  in  this 
apparent  tolerance,  and  it  is  always  dangerous  to  leave 
foreign  bodies  in  the  bronchi.  That  is  why  definite  search 
must  be  made.  Infection  and  broncho-pneumonia  are  to 
be  feared  with  a  bronchial  foreign  body.  Bar  j  on  has  often 
seen  patients  with  fever  and  bronchitis  two  or  three  weeks 
after  the  accidental  introduction  of  a  foreign  body.  The 
danger  is  still  greater  if  the  body  is  septic.  One  patient 
seen  by  Bar  j  on  had  carried  a  tracheotomy  tube  for  years 
without  taking  any  local  hygienic  care  of  it.  Oxidization 
had  corroded  all  the  circumference  of  the  neck  of  the  inside 
tube  which  became  detached  and  entered  the  right  bronchus. 


84  RADIO-DIAGNOSIS:  PLEURA 

It  was  a  particularly  septic  body.  In  spite  of  every  effort, 
the  tube  could  not  be  extracted  before  the  tenth  day;  the 
patient  already  had  a  temperature  of  SQ'"  C,  a  broncho- 
pneumonia had  developed  and  he  succumbed  in  spite  of 
successful .  bronchial  intervention.  Foreign  bodies  in  the 
bronchi  therefore  must  not  be  left  to  themselves. 

Diagtiosis. — When  a  patient  appears  with  the  history  of 
having  swallowed  a  foreign  body,  a  careful  examination 
ought  always  to  be  made.  The  foreign  body  may  be  either 
in  the  digestive  or  in  the  respiratory  tract.  If  it  has  pene- 
trated into  the  stomach  it  becomes  a  simple  matter  and 
elimination  will  be  normal. 

On  the  contrary,  if  it  remains  in  the  thoracic  region,  it 
must  be  considered  dangerous.  First  it  must  be  known 
whether  it  is  in  the  oesophagus  or  in  the  respiratory  tract. 
In  the  oesophagus  foreign  bodies  become  fixed  at  certain 
well  defined  points.  First  of  all,  at  a  point  above  the  sternal 
notch;  a  transverse  right  or  left  examination  easily  shows 
whether  it  is  in  the  oesophagus,  which  is  in  back,  or  in  the 
respiratory  tract,  which  is  in  front.  Second,  at  the  area  of 
stricture  caused  by  the  aortic  arch.  This  point  is  located 
an  appreciable  distance  above  the  bifurcation  of  the  bronchi, 
so  that  the  distinction  is  quite  easy  to  make.  Finally,  the 
third  point  is  at  the  intersection  of  the  diaphragm,  foreign 
bodies  of  the  respiratory  tract  never  descending  so  low. 
If  the  foreign  body  is  not  visible  radiologically,  if  there  is 
still  some  doubt  as  to  its  exact  location  or  even  if  sunply 
to  confirm  the  radioscopic  findings,  recourse  should  be  had 
to  both  bronchoscopic  and  oesophagoscopic  examination. 


CHAPTER  II 
BRONCHIAL  AFFECTIONS 

IN  a  general  way  bronchial  affections,  of  whatever 
nature,  do  not  give  important  radiological  images. 
In  bronchial  processes  there  is  always  present  an  apparent 
disagreement  between  the  many  auscultatory  signs  and 
the  slight  information  obtained  from  radioscopic  examina- 
tion. Processes  purely  bronchial  darken  the  lung  a  little. 
But  even  a  negative  examination  has  its  value,  for  it  elimi- 
nates as  a  cause  lesions  of  the  pulmonary  parenchyma. 

Acute  bronchitis. — Acute  bronchitis  does  not  give  any 
radioscopic  image  which  can  be  seen  on  the  screen.  There 
is  not  any  defined  shadow;  at  times,  a  very  slight  diminu- 
tion of  the  general  clearness  of  the  lungs.  The  affection 
develops  very  rapidly  to  produce  any  change  whatever  in 
the  bronchial  walls;  the  mucous  membrane  alone  is  con- 
gested and  it  does  not  give  any  appreciable  shadow.  There 
is  furthermore  no  glandular  involvement  sufficient  to  modify 
the  hilus  shadow. 

Chronic  bronchitis. — In  chronic  bronchitis  slight  modi- 
fications of  the  pulmonary  image  are  quite  often  seen,  but 
on  the  whole  the  general  clearness  is  scarcely  changed. 

The  hilus  shadow  is  a  little  more  pronounced,  enlarged 
and  especially  elongated  towards  the  base  of  the  lung.  The 
diverging  lines  which  arise  from  it  are  often  a  little  more 
accentuated  (peribronchitis),  forming  broader  and  darker 
lines,  especially  when  secretion  is  abundant.  The  bases, 
however,  retain  an  almost  normal  clearness;  the  convexity 
of  the  diaphragm  and  the  lateral  indentation  of  the  costo- 
diaphragmatic  sinus  are  not  modified;  the  amplitude  of  the 
respiratory  movements  is  not  reduced. 

The  appearance  of  the  apex  varies;  sometunes  it  is  a 

85 


86  RADIO-DIAGNOSIS:  PLEURA 

little  more  grayish  when  a  small  amount  of  sclerosis  is 
present,  sometimes  it  is  a  little  more  clear  if  compensatory 
emphysema  predominates. 

Bronchial  stenosis. — Stenosis  of  the  large  bronchus  is 
rather  rare  and  should  be  described  only  because  Holz- 
knecht  has  drawn  attention  to  a  radioscopic  sign  which  in 
his  opinion  would  be  characteristic  of  this  disease.  That 
is  the  inspiratory  displacement  of  the  mediastinum.  The 
lung  on  the  opposite  side  fills  more  quickly  and  better  during 
inspiration,  and  pushes  back  the  mediastinum  towards  the 
stenosis.  There  results  a  lack  of  equilibrium,  so  to  speak, 
between  the  two  lungs.  The  amount  of  air  being  less  active 
on  the  side  of  the  stenosed  bronchus,  the  other  lung  is  dis- 
tended more  quickly  and  occupies  a  more  considerable 
space. 

The  displacement  of  the  mediastinum  would  be  the  re- 
sult of  the  difference  in  pressure  between  the  two  lungs. 
Beclere  has  correctly  pointed  out  that  this  displacement  has 
nothing  pathognomonic  and  that  it  may  be  found  outside 
of  any  bronchial  stenosis.  A  unilateral  pulmonary  sclerosis 
may  bring  it  about,  the  median  space  no  longer  being  kept 
in  place  under  these  circumstances  by  ''two  equal  springs, 
pulling  against  each  other."  In  fact  the  sclerosed  lung  has 
become  almost  immobile  while  the  other  one  has  retained 
all  its  elasticity. 

Dilatation  of  the  bronchi. — Dilatation  of  the  bronchi  is  not 
always  recognizable  on  radioscopic  examination.  If  a  pa- 
tient with  this  disease  is  radioscoped  without  auscultation 
and  without  any  other  information  about  him,  it  is  highly 
probable  that  diagnosis  would  often  pass  unnoticed. 

In  no  other  thoracic  affection  is  the  contrast  so  marked 
between  the  importance  of  clinical  signs  and  the  insignifi- 
cance of  radiological  indications. 

Often  in  such  cases  nothing  further  is  determined  than 
what  was  pointed  out  in  chronic  bronchitis,  namely,  en- 
largement and  elongation  of  the  hilus  shadow  which  has 
become  more  opaque  and  a  more  marked  appearance  of  the 


Radiograph  14.     COPPER  EYELET  IN  THE  RIGHT  BRONCHUS 
The  copper  eyelet  with  a  hole  in  the  center  is  found  in  the  right  bronchus,  just 
at  the  level  of  the  hilus  against  the  right  edge  of  the  median  shadow. 


No.  1389.    J.  K. 
bronchi  on  right. 


Male 


Radiograph  15 
years  old.     Pulmonary  tuberculosis 


Dilatation  of 


Radiograph  16.     DILATATION  OF  THE  BRONCHI 
No.   101.     P.  C.     Male.     Age  35.     Clinical  history  and  examination:  Cough; 
loss   of  weight;  weakness.     Hyperresonance   over  whole   chest,   harsh   prolonged 
breathing.       No  rales.     X-ray  findings:  Emphysema.     General  bronchial  dilata- 
tion.   Some  peribronchial  thickening. 


Radiograph  17.  ADENOPATHY,  PRINCIPALLY  RIGHT  MEDIASTINAL 
AND  HILUS  REGION  SECONDARILY 

There  is  a  diffuse  shadow  the  entire  length  of  the  right  border  of  the  median 
shadow,  commencing  under  the  clavicle  and  extending  as  far  as  the  diaphragm 
with  very  appreciable  enlargement  in  the  hilus  region. 

Autopsy  (Pehu). — Tuberculous  meningitis.  A  caseous  mediastinal  adenopathy-, 
predominating  on  right.  Some  glands,  right  hilus.  Little  or  no  tuberculous  pul- 
monary change.  Double  broncho-pneumonia.  A  discrete  miliary  tuberculosis  of 
the  organs.    Tuberculous  mesenteric  glands. 


BRONCHIAL  AFFECTIONS  87 

diverging  lines  arising  from  it.  Yet  in  general  the  clearness 
of  the  bases  is  diminished  and  in  the  middle  of  this  diffuse 
grayish  mist  it  is  not  uncommon  to  see  either  clear  bands 
following  along  the  tract  of  the  dilated  bronchi  or  more 
opaque  shadows  situated  irregularly  and  corresponding  to 
the  retention  of  a  certain  amount  of  fluid  in  the  dilated  pe- 
ripheral bronchioles.  Barjon  has  never  found  radioscopic 
images  similar  to  those  of  pulmonary  cavities.  On  the  con- 
trary, he  has  always  found  a  very  great  difference  in  ap- 
pearance between  a  lung  affected  by  even  considerable 
bronchial  dilatation  and  a  lung  with  tuberculosis  in  process 
of  softening  or  already  filled  with  cavities.  Bronchial  dila- 
tation never  attains  the  same  degree  of  opacity  as  tuber- 
culosis. Opaque  shadows  are  found  only  when  a  new  process 
is  superadded. 

One  case  of  Barjon's  proved  very  instructive  in  this  re- 
spect,— a  woman  with  chronic  affection  of  the  right  lung 
with  cavity  signs  at  the  apex,  diffuse  sclerosis  of  the  lung 
with  resulting  secondary  dextrocardia.  The  radiographic 
image  showed  obscure  foci  unequally  divided  in  the  two 
lungs;  not  many  on  the  left;  they  were  somewhat  dense  in 
the  middle  of  the  right  lung  and  especially  confluent  toward 
the  base.  The  right  apex,  where  cavity  signs  were  heard, 
remained  clear.    Dextrocardia  was  clearly  visible. 

Examination  of  the  sputum  showed  absence  of  Koch 
bacilli;  the  tuberculin  test  was  negative  even  at  one-fifth 
more  than  the  normal  quantity.  Autopsy  showed  that  the 
patient  had  bilateral  bronchial  dilatation,  more  marked  on 
the  right  and  predominant  toward  the  apices.  There  were 
true  sub-pleural  cavities  in  which  the  dilated  large  bronchi 
ended.  Besides,  there  was  sclerosis  and  retraction  of  the 
right  lung  with  dextrocardia  and  symphysis ;  on  the  contrary, 
emphysema  was  predominant  on  the  left.  Death  was  due  to 
terminal  lobular  broncho-pneumonia  with  many  scattered 
foci  in  both  lungs  but  especially  in  the  lower  two-thirds  of 
the  right  lung.  These  foci  of  broncho-pneumonia  corre- 
sponded to  the  shadows  noted  on  the  radiographic  image. 


88  IL\DIO-DL\GNOSIS:  PLEURJE 

Histological  examination  confirmed  the  fact  that  there  was 
no  tuberculosis  but  ordinary  broncho-pneumonia. 

In  this  case,  abnormal  on  account  of  its  location  and  de- 
velopment, the  radioscopic  examination  was  not  at  fault. 
It  showed  that  the  right  apex  in  spite  of  the  presence  of 
cavity  signs  had  retained  its  normal  clearness  and  showed 
opaque  shadows  only  in  the  region  of  broncho-pneumonia 
areas. 

The  absence  of  a  characteristic  radiological  image  in  dila- 
tation of  the  bronchi  is  in  fact  certain  proof  and  allows 
diagnosis  to  be  made  bj^  elimination. 

The  important  clinical  signs  in  dilatation  of  the  bronchi 
may  suggest  either  tuberculosis  in  a  stage  of  softening  and 
with  cavities  at  the  base,  or  a  center  of  old  encysted  pleurisy 
incompletely^  evacuated.  But  in  these  two  cases  radioscopic 
examination  ought  to  show  very  characteristic  images:  pro- 
nounced opacity  of  the  lung,  clear  zones  corresponding  to 
the  cavities,  pleural  adhesions,  disappearance  or  partial 
efTacement  of  the  costodiaphragmatic  sinus,  elimination  or 
marked  diminution  of  the  respiratory  movements  in  the 
case  of  tuberculosis  of  the  base.  In  the  case  of  an  encysted 
pleurisy  there  is  a  defined  and  circumscribed  center  with  or 
without  an  appearance  of  pj^opneumothorax. 

In  dilatation  of  the  bronchi  there  is  nothing  comparable 
to  this;  bases  simply  a  little  gray,  no  appreciable  pleural 
reaction,  diaphragmatic  contour  and  sinus  well  preserved, 
respiratory  movements  almost  normal. 

In  proportion  as  the  clinical  signs  resemble  one  another, 
the  radiological  appearance  differs.  That  is  enough  to 
affirm  diagnosis. 


CHAPTER  III 

TRACHEO-BRONCHIAL  ADENOPATHY 

rp^HE  existence  of  tracheo-bronchial  adenopathy  is  very 
i  common  in  adults  as  well  as  in  children.  Often  it 
remains  latent  and  does  not  manifest  itself  by  any  functional 
disturbance.  At  times  it  gives  rise  to  disturbing  symptoms 
the  origin  of  which  it  is  very  important  to  know.  Investiga- 
tion of  these  deep  lymphatic  manifestations  is,  therefore, 
essential  in  many  cases  and  the  ordinary  methods  of  ex- 
ploration very  often  do  not  disclose  them.  These  latent 
forms  scarcely  attract  the  attention  of  the  clinician  and  yet 
it  is  essential  to  know  of  their  existence  in  order  to  make  a 
diagnosis. 

Percussion,  which  seems  to  be  the  best  method  of  examina- 
tion, is  a  very  delicate  and  uncertain  means  of  diagnosis. 
When  the  glands  are  large  enough  and  so  situated  as  to 
exert  sufficient  pressure  on  the  respiratory  tract,  compressed 
breathing  or  coughing  may  occur,  but  these  manifestations 
are  not  common.  It  is,  therefore,  indispensable  to  have  a 
more  certain  and  practical  method  of  investigation. 

Radioscopic  examination  seems  to  fulfill  these  demands 
and  diagnosis  of  tracheo-bronchial  adenopathy  can  actually 
be  affirmed  by  this  method  of  thorax  examination. 

Radioscopic  Distinction  between  Different  Groups 
OF  Glands. — The  anatomical  description  of  tracheo-bron- 
chial glands  has  been  made  by  Gueneau  de  Mussy  and 
Barety  and  since  adopted  by  most  anatomists. 

It  is  a  radiological  distinction  with  which  we  are  con- 
cerned, because  according  to  their  location,  these  different 
groups  of  glands  give  images  located  quite  differently  in 
comparison  with  the  normal  radioscopic  appearance  of  the 
thorax. 


90  RADIO-DIAGNOSIS:  PLEUR.E 

There  are  two  main  groups: 

1.  A  mediastinal  group  including  all  tracheo-bronchial 
glands,  that  is,  the  two  pre-tracheo-bronchial  groupings  right 
and  left  and  the  inter-tracheo-bronchial  grouping. 

All  these  glands  are  situated  in  the  median  line  between 
the  sternum  and  the  vertebral  column  in  relation  to  all  the 
important  organs  of  the  mediastinum.  Their  radioscopic 
images  will  be  mediastinal  images. 

2.  A  hilus  or  pulmonary  group  made  up  of  many  intra- 
pulmonary  peribronchial  glands  which  follow  the  bronchi 
subdivided  up  to  the  fourth  division  (Cruveilhier).  These 
glands  have  a  lateral  location  and  give  radioscopic  images 
which  will  be  hilus  or  pulmonary  images. 

This  distinction  is  radioscopically  important,  for  the 
images  furnished  by  these  different  groups  should  be  exam- 
ined and  studied  in  different  positions.  It  is  equally  im- 
portant from  a  pathogenic  point  of  view,  for  each  of  these 
locations  has  a  different  medical  significance. 

Different  IVIorphological  Significance. — Tracheo- 
bronchial adenopathy  of  the  mediastinal  group  usually 
corresponds  to  the  clinical  syndroma  in  children  described 
by  Gueneau  de  Mussy  and  Barety.  It  is  found  after  measles, 
whooping-cough  and  other  infectious  diseases  of  childhood; 
it  is  a  gland  affection  almost  exclusively,  not  in  any  way 
affecting  the  condition  of  the  lung. 

According  to  the  degree  of  pressure,  its  predominance  on 
the  respiratory,  vascular  or  nervous  organs,  the  sjonptoms 
that  appear  are  dyspnoea,  orthopnea,  pseudo-asthmatic,  or 
stridulous  crisis,  difficulty  in  breathing,  wheezing,  cynosis, 
oedema,  vocal  paralysis,  etc.  But  even  with  very  important 
gland  masses  there  is  often  no  appreciable  functional  trouble. 

In  adults  this  same  location  produces  symptoms  much  less 
striking  and  is  found  in  connection  with  the  development  of 
tuberculosis,  lymphadenitis,  cancer  of  the  breast,  oesophagus 
or  stomach. 

Adenopathy  of  the  hilus  group  is  much  more  directly 
related  to  the  condition  of  the  lung,  particularly  to  the 


Radiograph  18.  ADENOPATHY  PRINCIPALLY  IN  THE  HILUS  REGION 
AFFECTING  MEDIASTINUM 

No.  1982.  L.  C.  Female.  Clinical  history  and  examination:  Cough.  Slight 
fever.  Palpable  cervical  glands.  Sibilant  and  sonorous  rales  both  sides,  es- 
pecially left  base. 

X-ray  findings:  Hilus  region  enlarged.  Enlarged  hilus  glands.  Bases  increased 
density. 


Radiograph  19.     QUESTIONABLE  ADENOPATHY  OF  BOTH  THE  HILUS 
AND  MEDIASTINUM  BILATERALLY 
No.  1760.     S.  F.     Male,   15  years  old.     D'Espine's  sign  positive.     Dullness  to 
5th  dorsal  spine.     No  pulmonary  lesion.     Tracheo-bronchial  adenopathy. 


Radiograph  20.  TUMOR  OF  THE  ANTERIOR  SUPERIOR  MEDIAS- 
TINUM AFFECTING  THE  ADJACENT  GLANDS 

Enormous  shadows  in  the  superior  mediastinal  region,  extending  beyond  the 
median  shadow  on  both  sides.     Extension  to  the  entire  hilus  of  the  right  lung. 

Clinically. — Symptoms  of  pressure,  difficulty  in  breathing,  wheezing,  dyspnoea, 
raucous  cough. 


Radiograph  21.     A  RIGHT,  EXTENSIVE  PULMONARY  INFARCT  IN  A 

CARDIAC 
Very  large  heart.  Considerable  enlargement  of  the  median  shadow.  The  aorta 
and  the  pulmonary  artery  are  appreciably  deflected  to  the  left.  In  the  right  pul- 
monarj'  field  one  sees  an  extended,  elongated  shadow  occupying  the  lower  two- 
thirds,  from  the  median  portion  of  the  shoulder  blade  as  far  as  the  diaphragm. 
This  shadow  ends  in  a  point  in  the  lower  part. 


TRACHEOBRONCHIAL  ADENOPATHY  91 

development  of  pulmonary  tuberculosis  as  Pi6ry  and 
Jacques  have  well  shown,  but  may  also  precede  pulmonary 
lesions. 

These  glands  alone  do  not  cause  any  special  symptoms, 
but  their  occurrence  is  none  the  less  important  on  account 
of  the  seriousness  of  the  condition  revealed.  The  glands, 
however,  may  be  found  also  in  the  course  of  less  serious 
affections,  as  ordinary  bronchitis,  chronic  bronchitis  or 
bronchiectasis  which  produce  an  inflammation  and  per- 
manent infection  of  the  bronchial  tract,  causing  secondarily 
inflammation  and  hypertrophy  of  these  intrapulmonary 
glands. 

Radioscopic  image  and  differential  diagnosis. — I.  The  medi- 
astinal glands  do  not  appear  at  once  on  radioscopic  examina- 
tion. They  must  be  sought  for  and  that  is  the  reason, 
perhaps,  that  they  often  pass  undetected. 

In  the  frontal  and  dorsal  positions  the  image  of  the  glands 
is  confused  with  that  of  the  median  shadow.  This  median 
shadow  is  very  dense,  owing  to  the  superposition  of  succes- 
sive shadows  of  the  vertebral  column,  organs  of  the  medias- 
tinum and  sternum,  which  prevents  the  lighter  shadows  of 
the  glands  from  being  distmguished.  When  the  glands  are 
many  and  large  their  shadow  may  extend  laterally  beyond 
the  median  shadow,  giving  it  an  irregular  and  scalloped 
appearance.  Sometimes  the  shadow  of  the  glands  projects 
greatly  on  one  side  or  the  other.  But  this  image  may  be 
lacking. 

To  see  more  distinctly  the  shadow  of  these  glands,  the 
median  shadow  must  be  separated  by  having  the  patient 
assume  different  anterior,  posterior  and  oblique  positions 
so  that  the  mediastinum  can  be  investigated.  The  glands 
are  then  seen  as  a  diffuse  shadow  without  definite  outline, 
obscuring  the  middle  portion  of  the  corresponding  median 
clear  space  and  almost  level  with  the  bronchial  bifurcation. 
In  this  connection  Schwarz  has  observed  that  before  radio- 
scopic examination  this  bifurcation  had  been  placed  as 
much  too  high.     In  reality  it  corresponds  to  the  sixth  rib 


92  RADIO-DIAGNOSIS:  PLEURAE 

posteriorly;  consequently,  mediastinal  adenopathy  ought 
to  be  looked  for  at  this  level  or  above,  while  pulmonary 
adenopath^s  situated  lower  down,  corresponds  to  the  seventh 
or  eighth  rib. 

IMediastinal  adenopathy,   especially  if  large  and  if  its 
image  projects  beyond  the  median  shadow,  may,  strictly 


Fig.  19.     DIAGRAM  OF  THE  DISTRIBUTION  OF  THE  GLANDS,  AFTER 

AUTOPSY 
Predominance  of  mediastinal  glands  on  the  right  side  occupying  the  entire 
length,  superimposed  one  upon  another  from  the  diaphragm  up  to  the  clavicle. 
Two  caseous  glands  in  the  right  hilus  (see  Radiograph  17). 

speaking,  be  confused  in  children  with  hypertrophy  of  the 
thymus  and  in  adults  with  tumor  of  the  mediastinum. 

Differential  diagnosis  from  thymic  hypertrophy  is  com- 
paratively easy,  the  latter  giving  a  radioscopic  image  more 
elevated,  located  under  the  clavicles  and  usually  with  a 
contour  almost  rectilinear  and  symmetrical  on  both  sides. 
This  image  superimposed  on  that  of  the  heart  has  roughly 
the  appearance  of  an  hour-glass.  Besides,  thymic  hyper- 
trophy is  found  only  in  the  new  born  while  tracheo-bronchial 
adenopathic  syndroma  is  rather  the  usual  accompaniment 
of  childhood.  Age  will  therefore  be  an  important  factor  to 
consider  and,  on  the  other  hand,  as  the  thymus  and  other 


TRACHEO-BRONCHIAL  ADENOPATHY     93 

glands  are  each  amenable  to  radiotherapic  treatment,  in 
case  of  doubt,  irradiations  can  always  be  prescribed.  In 
adults  the  diagnosis  of  mediastinal  tumor  is  often  difficult, 
the  tumor  being  accompanied  by  mediastinal  adenopathy. 
However,  the  tumor  usually  reaches  a  size  which  the  glands 
do  not  and  is  accompanied  by  phenomena  of  pressure  un- 
common in  simple  adenopathies. 

II.  The  hilus  glands,  due  to  their  intrapulmonary  lateral 


Fig.  20.     DIAGRAM  OF  ARRANGEMENT  OF  GLANDS  AFTER  AUTOPSY 
Adenopathy,  especially  of  the  hilus  region,  four  caseous  glands  adherent,  situated 
on  the  right.    On  the  mediastinal  side  a  rather  large  gland  with  long  vertical  axis 
and  two  other  smaller  glands  (see  Radiograph  18) . 

location,  give  an  image  distinct  from  the  median  shadow 
easy  to  see  in  the  frontal  and  dorsal  positions. 

This  shadow  is  confused  with  that  of  the  hilus  which, 
consequently,  is  broader,  longer  and  more  dense.  The 
extension  is  on  the  side  of  the  lung  principally  toward  the 
base. 

When  it  is  not  too  extensive,  a  clear  thin  space  separates 
it  from  the  median  shadow,  but  if  the  adenopathy  progresses 
even  a  little,  the  hilus  shadow  is  extended  and  fuses  with 
the  median  shadow  from  which  it  cannot  be  distinguished. 
This  appearance  coincides  ordinarily  with  rather  extensive 
and  advanced  pulmonary  lesions.     But  early  tuberculosis 


94  RADIO-DIAGNOSIS:  PLEURAE 

of  the  glands  of  the  hihis  with  caseation  and  without  pul- 
monary lesion  is  not  unconnnon. 

The  hilus  shadow  is  not  always  homogeneous;  often 
darker  spots  appear  in  the  middle  of  the  diffuse  grayish 
tint,  due  to  the  presence  of  denser  glands,  particularly 
fibrous  or  calcareous  glands.  It  is  more  apparent  on  the 
right  where  nothing  obscures  it,  while  on  the  left  it  is  largely 
covered  by  the  heart  shadow. 

Piery  and  Jacques  attach  a  certain  amount  of  importance 
to  the  appearance  of  the  hilus  shadow  in  the  different  forms 
of  tuberculosis.  It  should  appear  as  a  uniform  band,  not 
well  defined,  in  incipient  tuberculosis;  a  very  marked  ho- 
mogeneous band  in  the  subacute  forms;  dark  spots  should 
stand  out  on  this  grayish  band  in  clironic  forms;  and  finally 
in  latent  tuberculosis  very  clear  spots  with  well  defined 
outlines  should  be  seen.  In  reality,  it  is  difficult  to  be  guided 
by  this  examination.  Tuberculosis  which  remains  a  long 
time  latent  may,  according  to  circumstances,  develop  into 
an  acute,  subacute  or  chronic  form.  All  that  is  necessary  to 
bear  in  mind  is  that  the  presence  of  deeper  and  more  de- 
fined shadows  in  the  midst  of  homogeneous  hilus  bands 
corresponds  to  sclerous  or  calcareous  glands,  denser  than 
simple  hypertrophied  or  caseous  glands. 

In  fact  Piery,  Jacques  and  Nogier  have  demonstrated 
that  by  examining  under  an  equal  thickness  of  layers  simple 
hypertrophied,  sclerous,  calcified  or  caseous  glands,  shadows 
of  different  values  will  be  obtained. 

Calcified  and  sclerous  glands  give  black  spots  with  well 
defined  outline.  Simple  hypertrophied  glands  give  a  deep 
shadow  with  ill  defined  outline.  Purely  caseous  glands  seem 
to  be  the  most  transparent. 

Diagnosis  of  these  gland  images  of  the  hilus  is  not  always 
evident.  Pleural  or  pulmonary  lesions  may  furnish  analo- 
gous images. 

A  thickening  of  the  pleura  in  the  region  of  the  hilus  may 
give  diffuse  shadows  but  they  are  generally  less  apparent, 
more  homogeneous  and  especially  less  mobile.     When  the 


TRACHEO-BRONCHIAL  ADENOPATHY     95 

tube  is  moved  the  gland  shadows  are  displaced  in  the  oppo- 
site direction  and  sometimes  from  one  intercostal  space  to 
another  on  account  of  their  relative  distance  from  the 
screen  and  their  somewhat  deep  location.  Thickenings  of 
the  pleura  which  are  more  superficial  and  are  brought  nearer 
the  screen  are  displaced  very  little  or  not  at  all. 

Small  pleural  encysted  collections  in  the  region  of  the 
hilus  give  an  image  much  more  like  that  of  the  glands.  This 
has  already  been  spoken  of  in  connection  with  encysted 
pleurisy.  Diagnosis  should  be  made  particularly  according 
to  development;  encysted  pleurisy  either  extends  well  to- 
wards another  portion  of  the  pleura  (interlobe,  large  cavity), 
and  then  gives  a  characteristic  image;  or  resolves  and  dis- 
appears in  a  few  days  when  the  glands  give  an  image,  if  jiot 
permanent,  at  least  persisting  for  a  long  time. 

Tumors  of  the  mediastinum  give  more  important  shadows 
and  are  most  often  accompanied  by  secondary  adenopathy. 

The  presence  of  a  diffuse,  extensive  shadow  going  well 
beyond  the  limits  of  the  properly  called  hilus  region  will 
probably  mean  a  concomitant  lesion  of  the  lung,  and  auscul- 
tation will  show  the  condition  of  the  lung.  It  must  not  be 
forgotten,  however,  that  glands  of  the  hilus  are  prolonged 
as  far  as  the  bronchi  of  the  fourth  division  and  that  they 
may  give  rather  extensive  images. 

In  summing  up,  two  distinct  forms  of  tracheo-bronchial 
adenopathy  exist:  a  mediastinal  and  a  hilus  form,  which 
ought  to  be  distinguished  radiologically.  Clinically  these 
forms  are  most  often  associated. 

Bar j  on  has  insisted  on  this  division  in  order  to  draw 
attention  to  the  different  location  of  these  two  groups,  the 
particular  appearance  of  their  images  and  the  different 
way  in  which  they  must  be  studied :  frontal  and  dorsal  posi- 
tions for  the  glands  of  the  hilus;  oblique  positions  for  the 
mediastinal  glands. 

In  reality,  this  distinction  is  somewhat  artificial,  for  the 
same  causes  ordinarily  affect  both  groups.  Mediastinal 
adenopathy  in  children  is  usually  accompanied  by  a  hilus 


96  RADIO-DIAGNOSIS:  PLEUR.E 

adenopathy;   hilus   adenopathy   in   adults   ahnost   always 
ends  with  a  mediastinal  adenopathy. 

Too  much  importance,  therefore,  must  be  not  attached 
to  this  distinction  which  is  only  meant  to  bring  out  better 
the  anatomical  and  radioscopic  individuality  of  each  group. 
What  ought  to  be  borne  in  mind  is  the  clinical  and  prognos- 
tic value  of  adenopathy  which  is  always  serious.  Undoubt- 
edly in  adults  it  may  sometimes  indicate  only  a  chronic 
and  benign  affection  of  the  bronchi,  but  very  often  in  children 
with  general  poor  health  they  are  an  almost  certain  indica- 
tion of  tuberculosis. 


PART  IV 
RADIOLOGICAL  STUDY  OF  THE  LUNGS 


CHAPTER  I 
VASCULAR  PROCESSES 

THE  vascular  processes:  congestions,  oedemas,  infarct 
give,  from  a  radiological  point  of  view,  a  series  of  ab- 
normal shadows  which  it  is  well  to  recognize  but  which  do 
not  have  a  pathognomonic  value.  It  is  always  the  clinical 
examination  which  reveals  these  manifestations.  The  radio- 
scope  can  only  serve  to  give  information  which  confirms  their 
existence  and  allows  one  to  determine  their  location. 

Congestions. — Pulmonary  congestions  are  frequent  and 
of  very  different  forms.  They  always  show  a  very  percep- 
tible diminution  of  clearness  in  the  zone  attacked  when  the 
thorax  is  examined  on  the  screen.  We  can  distinguish: 
primary  active  congestion,  secondary  active  congestion, 
passive  congestion. 

(a)  Primary  active  congestion. — Here  it  is  an  acute  disease 
which  resembles  pneumonia  and  pleurisy  and  of  which  the 
diagnosis  is  sometimes  rather  difficult  to  establish.  There 
are  three  clinical  forms  to  be  distinguished:  The  pneumonic 
form  (Woillez),  the  pleuro-pneumonic  form  (Potain),  and 
the  spleno-pneumonic  form  (Grancher).  Radioscopic  exam- 
ination may  be  useful  in  differentiating  these  acute  conges- 
tions from  true  pneumonia  and  also  in  distinguishing  the 
various  forms  of  congestion  which  have  just  been  pointed 
out.  Diagnosis  in  frank  pneumonia  is  often  difficult,  clin- 
ically. Radioscopic  examination  shows  that  a  shadow  as 
opaque  or  as  clearly  defined  as  in  pneumonia  never  exists. 
The  pneumonic  triangle  is  lacking.  When  the  signs  of  effu- 
sion are  added  to  pulmonary  symptoms,  radioscopic  exam- 
ination will  indicate  whether  or  not  there  is  fluid  in  the  pleura. 
If  the  existence  of  a  slight  concomitant  effusion  is  established, 
it  indicates  pleuro-pneumonic  congestion  of  the  Potain  tj^e. 

99 


100  IL\DIO-DIAGNOSIS:  LUNGS 

If  the  radioscope  shows  the  absence  of  all  efifusion,  then  we 
have  to  do  with  the  spleno-pneumonic  form  of  Grancher. 

(b)  Seco?idary  active  congestion. — Attacks  of  active  sec- 
ondary congestion  are  produced  in  the  course  of  different 
affections^infectious  diseases,  especially  tj^phoid  fever, 
grippe,  malaria,  etc.  Radioscopic  examination  in  these  cases 
shows  only  diffuse  shadows,  at  times  lighter  and  without  any 
particular  characteristic.    Its  role  is  then  supplementary. 

(c)  Passive  congestion. — This  occurs  at  the  bases,  either 
in  patients  with  prolonged  dorsal  decubitus  or  more  often 
still  in  cardiacs.  Such  congestion  is  often  accompanied  by 
a  small  amount  of  oedema  and  when  it  recurs,  it  sets  up  in 
the  lung  a  sort  of  chronic  inflammation  which  ends  in  sclero- 
sis. The  diffuse  radioscopic  shadow  which  is  then  seen  at 
the  base  of  the  lung  is  often  the  result  of  this  triple  process, — 
congestion,  oedema,  sclerosis. 

(Edemas. — (Edemas  give  diffuse  shadows  which  resemble 
to  a  noticeable  degree  those  produced  by  congestions.  Acute 
active  oedema  which  is  produced  in  the  course  of  arterio- 
cardiopathies  and  nephritis  is  shown  by  a  diffuse  shadow  of 
variable  extent,  occupying  sometimes  two-thirds  of  both 
lungs,  more  marked  at  the  bases,  less  dense  toward  the 
apices.  It  may  be  much  more  marked  on  one  side,  at  times 
clearly  unilateral. 

Passive  chronic  oedema  attacks  the  bases  and  is  found 
in  mitral  cardiacs;  it  is  shown  on  the  screen  by  a  thinning, 
more  or  less  marked,  of  the  thoracic  clearness  toward  the 
lower  portion  of  the  lung. 

Radioscopic  characteristics  common  to  oedema  and  to  con- 
gestion of  the  bases. — These  passive  conditions  are  seen  always 
on  the  screen  as  diffuse  shadows,  ordinarily  not  very  deep 
and  of  very  variable  extent.  They  are  distinguished  by 
certain  characteristics  from  shadows  produced  by  effusion, 
even  though  this  is  slight.  The  opacity  is  never  as  intense 
as  that  produced  by  effusion.  The  permeability  of  the  lung 
ha\'ing  been  retained  in  part,  the  air  which  penetrates  into 
the  alveolars  modifies  the  shadow  produced  by  excess  of 


VASCULAR  PROCESSES  101 

serous  fluid.  In  inspiration  the  base  becomes  sufficiently 
cleared  for  one  to  distinguish  plainly  the  convex  contour  of 
the  diaphragm  and  the  notching  of  the  costodiaphragmatic 
sinus.  The  movements  of  respiration  have  kept  their 
regularity  and  their  extent.  It  is  then  certain  that  there  is 
no  question  of  effusion. 

Infarct. — Infarct  of  the  lung,  when  it  affects  a  sufficient 
area,  can  by  radioscopic  examination  present  a  very  percep- 
tible abnormal  shadow.  Contrary  to  what  the  anatomic 
aspect  of  the  lesions  would  lead  one  to  suspect,  this  shadow 
is  not  very  opaque  and  does  not  usually  show  contours 
clearly  defined.  It  does  not  have  the  frank  triangular  form 
and  should  not  be  confused,  for  example,  with  the  pneumonic 
triangle.  It  has  neither  its  appearance,  its  intensity,  nor 
its  position.  It  shows  ordinarily  on  the  screen  as  a  blurred 
spot  with  shaded  contours,  situated  most  often  in  the  full 
pulmonary  field,  but  rather  in  the  lower  part  of  this  field. 
This  blurred  aspect  of  infarct  is  due,  undoubtedly,  to  the 
inflammatory  zone  which  surrounds  it,  already  well  de- 
scribed by  Laennec,  and  which  contains  a  certain  degree 
of  oedematous  infiltration.  On  the  radiographs  the  contour 
of  the  infarct  is  a  little  more  clearly  visible  but  the  shadow 
remains  not  very  opaque  unless  it  is  a  very  extensive  infarct. 
Even  in  that  case  one  never  sees  an  intensity  comparable  to 
that  of  lobar  pneumonia. 


CHAPTER  II 
ACUTE  INFECTIOUS  PULMONARY  PROCESSES 

PNEUMONIA. — Radioscopic  examination  is  valuable 
in  pneumonia  either  to  facilitate  diagnosis,  to  deter- 
mine its  location,  or  to  follow  its  development.  By  reason 
of  its  form  and  its  different  development  it  is  invaluable  in 
distinguishing  the  characteristics  of  pneumonia  in  children 
from  that  in  adults. 

Pneumonia  in  children — Radioscopic  study  of  infantile 
pneumonia  has  been  made  in  a  very  complete  manner  by 
Weill  and  Mouriquand  in  numerous  reports  from  which  we 
shall  quote  largely.  The  pneumonia  of  childhood,  and  in 
particular  that  of  infancy,  is  most  often  difficult  to  detect 
because  the  physical  signs  may  appear  only  slowly,  or 
even  may  be  lacking  completely.  The  pneumonia  with  its 
general  symptoms — fever,  vomiting — precedes  pulmonary 
localization,  which  often  becomes  perceptible  only  on  the 
4th,  5th  and  even  the  9th  day.  Radioscopic  examination, 
on  the  contrary,  early  discloses  pulmonary  localization, 
showing  an  image  quite  characteristic. 

The  pneumonic  triangle. — This  image  appears  under  the 
form  of  a  triangular,  opaque  shadow — "primary  triangle" — 
the  base  of  which  corresponds  to  the  axilla  while  the  apex  is 
directed  towards  the  hilus.  In  the  beginning  this  figure  is 
clear ;  later  it  may  be  modified  by  processes  drawn  out  toward 
the  apex  or  toward  the  base,  diffusing,  extending,  or  even 
deforming  the  shadow.  Then,  during  the  period  of  resolu- 
tion, these  superadded  shadows  disappear  first  and  the 
primary  figure  is  restored  again  under  the  name  of  ''triangle 
de  retour." 

Diagjiosis. — Radioscopic  examination  is  a  valuable  aid  in 
diagnosis,  for  it  reveals  the  existence  of  a  pneumonic  focus 

102 


Radiograph  22.     RIGHT  FRANK  PNEUMONIA  WITH   RAPID   DEFER- 
VESCENCE IN  A  CHILD 
The  upper  external  portion  of  the  right  pulmonary  field  is  occupied  by  a  tri- 
angular shadow,  very  opaque,  with  contours  clearly  marked  (pneumonic  triangle). 


Radiograph  23.     ACUTE    RIGHT    LOBAR    PNEUMONIA    IN    A    CHILD 
WITH  RAPID  FEBRILE  DECLINE 
No.   1952.     R.  O.     Male,   15  months  old.     Pneumonia  in  right  upper  lobe  of 
4  days'  duration  with  typical  clinical  history  and  phj'sical  findings. 


ACUTE  INFECTIOUS  PULMONARY  PROCESSES     103 

before  auscultation.  Often  auscultation  reveals  nothing,  or 
scarcely  a  diminution  of  the  vesicular  murmur,  the  breathing 
and  rales  appearing  only  afterwards.  There  are  even  pneu- 
monic foci  which  remain  latent  to  the  end  and  which  would 
never  have  been  brought  to  light  without  the  radioscopic 
screen.  On  the  other  hand,  these  proofs  do  away  with  the 
idea  of  a  central  pneumonia  which  would  explain  the  late 
appearance  of  physical  signs.  Indeed,  the  shadow  of  the 
pneumonic  triangle  begins  always  at  its  base,  and  this  base 
is  always  cortical  since  it  develops  in  the  axilla. 

Finally,  the  radioscope  never  shows  in  any  case  a  primary 
central  focus  without  some  relation  to  the  cortical  portion 
of  the  lung.  In  short,  central  pneumonia  does  not  exist,  but 
everything  progresses  clinically  as  if  it  did. 

Prognosis. — Radioscopic  examination  furnishes  also  an 
element  of  prognosis  in  the  study  of  infantile  pneumonia. 
In  fact,  when  the  pneumonic  focus  remains  limited  to  the 
primary  triangle  without  any  tendency  to  extend,  when  the 
localization  appears  slowly,  the  prognosis  is  favorable.  An 
early  localization  with  rapid  extension  indicates  a  more 
serious  form.  Finally,  when  the  localization  appears  at  the 
outset  at  the  same  time  as  fever  and  general  symptoms,  the 
pneumonic  triangle  has  only  a  transitory  existence  and 
hepatization  rapidly  affects  the  whole  parenchyma.  This 
evolution  occurs  with  a  particularly  serious  form  and  in  this 
case  infantile  pneumonia  resembles  in  form  and  development 
that  of  the  adult. 

Pneumonia  in  adults. — Radioscopic  examination  is  of  less 
interest  with  adults  than  with  children  in  the  course  of 
pneumonia.  Clinical  diagnosis  is,  in  general,  much  easier 
with  the  adult  where  physical  signs  are  rarely  lacking  and 
are  even  somewhat  early.  On  the  other  hand,  adult  pneu- 
monia is  a  disease  much  more  serious  than  infantile  and  the 
carrying  of  such  a  patient  to  the  radioscopic  room  in  acute, 
developed  pneumonia  is  at  the  same  time  a  great  difficulty 
and  a  grave  danger. 

Therefore,  the  examinations  are  exceptional  in  the  early 


0 


104  RADIO-DIAGNOSIS:  LUNGS 

stages  and  are  usually  made  during  the  first  days  which 
follow  defen^escence.  This  is  perhaps  one  reason  which 
explains  the  rarity  of  the  pneumonic  triangle  in  the  adult. 
The  late  examination  does  not  give  the  primary  triangle 
phase,  but  most  often  only  a  diffuse  lobar  shadow.  Yet  we 
must  confess  that  if  the  primary  triangle  is  rare  in  adults, 
the  "triangle  de  retour"  is  none  the  less  so,  which  leads  us 
to  suppose  that  the  triangular  form  is  not  as  a  rule  in  the 
adult  the  pathognomonic  image  of  pneumonia.  It  does 
occur,  however.  This  has  been  pointed  out  by  Bret  and  by 
^Mollard  in  the  course  of  prolonged  pneumonia.  Paillard 
has  seen  two  cases  of  it.  Barjon  observed  it,  as  shown  by 
the  accompanying  radiograph  (Radiograph  24) ,  but  it  is  not 
the  usual  form.  The  early  lobar  form  and  the  slowness  of 
resolution  distinguish  radiographically  pneumonia  in  adults. 
In  children  the  pneumonic  triangle  is  the  rule.  It  often  con- 
stitutes in  itself  the  entire  pneumonia.  The  lobar  form  is 
late  and  more  rare.  In  adults  the  pneumonic  triangle  is 
less  frequent  and  appears  to  be  only  a  passing  form  and  the 
entire  lobe  is  rapidly  affected. 

The  most  characteristic  picture  is  that  of  pneumonia  of 
the  apex.  The  whole  upper  lobe  is  obscured,  as  far  down  as 
the  interlobar  line  which  separates  it  from  the  clearness  of 
the  lower  lobe.  The  line  of  demarcation  is  clear,  the  con- 
trast striking. 

In  pneumonia  of  the  base  the  picture  is  less  characteristic, 
the  shadow  more  diffuse,  its  outline  less  certain. 

In  massive  pneumonia  the  diffuse  shadow  covers  the  entire 
hemithorax  and  the  lung  with  complete  hepatization  shows 
a  marked  increase  in  size  so  that  there  results  a  certain 
amount  of  displacement  of  the  heart  and  of  the  mediastinum 
to  the  opposite  side,  as  occurs  in  pleurisy.  It  is  not  rare 
besides  to  see  these  pneumonias  complicated  with  a  slight 
pleural  effusion. 

The  resolution  of  pneumonia  can  be  easily  followed  on  the 
radioscopic  screen.  In  children,  when  pneumonia  is  benign 
(which  is  the  rule),  and  when  the  radioscopic  picture  is 


ACUTE  INFECTIOUS  PULMONARY  PROCESSES    105 

limited  to  the  primary  triangle,  resolution  is  rapid  and  in  a 
few  days  all  trace  of  an  abnormal  shadow  has  disappeared  in 
the  lung.  It  is  only  in  the  more  serious  forms  when  the  lobar 
shadow  succeeds  the  primary  triangle  that  resolution  becomes 
slower  and  the  abnormal  shadow  still  persists  at  the  end  of 
several  weeks. 

In  adults  the  resolution  of  pneumonia  is  always  slow,  but 
in  certain  serious  and  extensive  forms  it  is  prolonged  in  a 
manner  quite  remarkable.  The  abnormal  shadow  of  the 
lung,  more  transparent  and  modified,  persists  a  long  time 
after  the  disappearance  of  all  physical  signs.  Bar j  on  found 
it  in  a  case  two  and  a  half  to  three  months  after  the  be- 
ginning of  pneumonia,  but  usually  it  can  be  followed  for 
at  least  six  weeks.  The  shadow  becomes  lighter,  less  ho- 
mogeneous, loses  form  and  sometimes  is  reduced  to  a  long 
band,  more  or  less  irregular,  almost  always  cortical,  but  it  is 
effaced  only  very  slowly  and  a  long  time  after  the  disap- 
pearance of  all  auscultatory  signs.  It  may  be  said,  then,  of 
the  pneumonic  shadow  that  whereas  in  children  it  often 
precedes  by  several  days  the  appearance  of  stethoscopic 
signs,  it  outlasts  them  in  the  adult  sometimes  for  several 
weeks. 

Has  the  pneumonic  triangle  a  specific  value  in  the  radio- 
logical diagnosis  of  acute  frank  pneumonia? — When  it  exists, 
its  positive  value  is  unquestionable,  especially  with  children. 
No  other  thoracic  disease  gives  a  triangular  shadow  with 
an  axillary  base  and  with  contours  so  distinct.  Interlobar 
pleurisy  gives  a  more  regular  band  which  has  not  the  form 
of  an  angle.  It  begins  in  the  region  of  the  hilus  and  extends 
afterwards  to  the  whole  interlobe.  The  pneumonic  triangle, 
on  the  contrary,  begins  at  the  axilla  and  the  base  of  the 
triangle  is  visible  often  before  its  apex.  Consequently  its 
progress  is  inverse. 

It  would  seem  a  priori  that  infarct  by  reason  of  its  anatom- 
ical form  would  show  on  the  screen  a  clear  picture  in  tri- 
angular form,  but  it  does  not.  Infarct,  contrary  to  what 
one  would  think,  shows  on  radioscopic  examination  light 


106  RADIO-DIAGNOSIS:  LUNGS 

borders  poorly  defined  by  reason  of  the  inflammatory  process 
which  surrounds  the  hemorrhagic  focus.  However,  infarct 
is  exceptional  in  children.  In  certain  conditions  other  pul- 
monary processes  and  in  particular  tuberculosis  maj''  show 
the  axillar}'  triangle. 

The  development  of  tuberculosis  is  often  brought  about 
only  through  a  series  of  pneumonic  processes.  At  different 
times  Barjon  established  the  presence  of  the  axillary  triangle 
in  tuberculous  patients.  Others  have  made  the  same  state- 
ment. Nevertheless,  this  pneumonic  picture,  however  clear 
it  may  be,  is  distinguishable  from  that  of  frank  pneumonia, 
for  there  are  seen  either  on  the  same  side  or  on  the  opposite 
side,  shadows  caused  by  pre-existing  tuberculous  lesions 
(see  Radiograph  26). 

Clinically  these  pneumonic  foci  show  neither  the  same 
development  nor  the  same  symptoms  as  frank  pneumonia. 
These  facts  do  not  at  all  lessen  the  value  of  the  pneumonic 
triangle.  When  the  triangle  is  wanting,  one  has  no  right 
to  deny  pneumonia.  We  have  seen  that  this  characteristic 
picture  is  rare,  transitory,  in  adults ;  that  it  may  be  wanting 
in  a  very  great  number  of  cases.  In  children  even  the  tri- 
angle may  not  be  present,  as  Weill  and  Mouriquand  have 
shown,  but  that  is  much  more  rare. 

To  sum  up,  the  triangle,  when  it  exists,  has  all  the  value 
of  a  positive  sign  and  one  must  conclude  the  existence  of  a 
pneumonic  process. 

Broncho-Pneumonia. — Broncho-pneumonia  appears  un- 
der two  different  forms :  a  diffuse,  extensive,  or  pseudo-lobar 
form;  and  a  form  with  distinct,  disseminated  foci,  or  lobular. 
In  these  two  cases  the  radioscopic  pictures  are  quite  dif- 
ferent. 

Pseudo-lobar  form.  —  Pseudo-lobar  broncho-pneumonia 
never  shows  an  outline  as  definite  as  pneumonia.  It  is  ex- 
ceptional to  see  it  occurring  within  the  exact  limits  of  one 
lobe.  Most  often  it  affects  only  a  more  or  less  important 
fraction  of  the  lobe,  or  spreads  from  one  lobe  to  another, 
limiting  itself  either  to  the  anterior  portion,  or  more  often, 


Radiograph  24.     ACUTE  LOBAR  PNEUMONIA   OF  THE   RIGHT  APEX 
IN  AN  ADULT.    PNEUMONIC  TRIANGLE 
No.  111.    M.  T.    Female,  7  years  old.    Pneumonia  in  right  upper  lobe  of  5  days' 
duration  with  typical  physical  findings. 


Radiograph  25.  TOTAL  DIFFUSE  PNEUMONIA  OF  THE  RIGHT  LUNG 
IN  AN  ADULT  WITH  PREDOMINANCE  TOWARD  THE  BASE.  DIS- 
PLACEMENT OF  THE  HEART  AND  MEDIASTINUM 

Diffuse  and  total  obscurity  of  the  entire  right  lung,  more  marked  in  the  lower 
two-thirds.  The  preservation  of  the  convex  contour  of  the  diaphragm  and  of  the 
deep  indentation  of  the  costodiaphragmatic  sinus  shows  that  there  is  no  effusion 
in  the  pleura.  Nevertheless  one  sees  some  displacement  to  the  left  of  the  heart 
and  of  the  mediastinum  on  account  of  the  extent  of  the  pneumonic  process  and  the 
increase  in  volume  of  the  right  lung  which  results  from  it. 


ACUTE  INFECTIOUS  PULMONARY  PROCESSES     107 

to  the  posterior  portion  of  the  luri^.  Evidently  such  a 
localization  cannot  give  shadows  as  distinct  and  with  con- 
tours as  definite  as  those  of  pneumonia.  Bronciio-pncunionia 
never  gives  the  picture  of  the  pneumonic  triangle;  but  shows 
only  diffuse  shadows,  obscure,  poorly  defined,  and  often 
scarcely  apparent.  The  clinical  and  radiological  symptoms 
taken  together  permit  of  a  diagnosis. 

While  in  penumonia  clinical  signs  may  be  lacking  or  re- 
main unsuspected  in  the  beginning,  there  is  already  a  very 
distinct  opaque  shadow  in  the  axillary  region  or  in  the  upper 
lobe.  In  broncho-pneumonia,  on  the  contrary,  the  signs 
are  very  audible  and  extensive  (breathing,  moist  rales)  and 
it  is  surprising  on  radioscopic  examination  co  see  shadows 
so  light,  diffuse  and  difficult  to  make  out  in  spite  of  a  train 
of  symptoms  so  alarming.  This  is  due  to  the  dissemination 
of  the  lesions  and  the  persistence  of  normal  areas  either  in 
front  or  in  back  on  the  surface  of  the  lung.  The  relative 
clearness  retained  in  the  normal  areas  lessens  the  value  of 
the  shadows  thrown  by  the  diseased  areas  while  in  penu- 
monia, which  forms  a  solid  mass,  the  opacity  is  more  ap- 
parent. It  seems,  too,  that  the  anatomical  process,  which 
is  different  in  pneumonia  and  broncho-pneumonia,  helps 
to  accentuate  this  contrast  in  shadows.  There  are,  however, 
cases  where  the  differentiation  is  more  difficult,  where  the 
focus  of  broncho-pneumonia,  more  condensed,  gives  a 
shadow  more  important  and  somewhat  difficult  to  distin- 
guish from  that  of  pneumonia,  especially  when  it  occurs  in 
the  upper  lobe.  Bar j on  demonstrated  several  cases  of  it — 
one  in  Dr.  Pehu's  service  which  was  confirmed  by  autopsy. 

Lobular  form. — Lobular  broncho-pneumonia  appears  an- 
atomically under  the  form  of  disseminated,  distinct  foci. 
These  foci  may  be  very  near  together  and  confluent  in 
certain  parts  of  the  lung,  obscure  and  far  apart  in  others. 
Nevertheless,  as  the  mass  of  the  lung  has  retained  its  trans- 
parency, each  of  these  foci  gives,  on  radioscopic  examina- 
tion, a  definite  shadow  which  stands  out  against  the  clear 
background  of  the  parenchjTiia,.    The  radioscopic  image  of 


108  RADIO-DL\GNOSIS:  LUNGS 

this  form  of  broncho-pneumonia  is  thus  made  up  of  a  series 
of  distinct  shadows,  more  or  less  confluent,  and  separated 
from  one  another  by  clear  spaces.  It  has  exactly  the  ap- 
pearance of  certain  forms  of  chronic  tuberculosis  with  dis- 
seminated foci  which,  however,  are  nothing  else  than  foci 
of  tuberculous  broncho-pneumonia.  The  lung  shows  a 
mottled  appearance. 

This  appearance  is  clearly  shown  in  Radiograph  16 — a 
series  of  diffuse,  definite  shadows,  much  more  confluent  at 
the  right  towards  the  base  and  the  region  of  the  hilus,  much 
more  questionable  at  the  left.  This  was  a  case  of  a  lobular 
broncho-pneumonia,  verified  by  autopsy,  in  which  the  con- 
fluence of  the  diseased  centers  was  perfectly  visible  on  the 
plate.  It  was  a  common  broncho-pneumonia,  following  a 
chronic  bronchial  infection,  and  not  a  case  of  tuberculosis. 
The  clinical  development,  the  absence  of  bacilli  in  the  spu- 
tum, and  the  absence  of  tuberculin  reaction  indicated  that 
tuberculosis  was  not  a  cause.  Autopsy  and  histological 
examination  of  the  lung  confirmed  this.  It  is  evident  then 
that  simple  lobular  broncho-pneumonia  may  give  a  radio- 
scopic  picture  analogous  to  that  of  certain  forms  of  chronic 
tuberculosis  with  disseminated  foci  and  that  it  is  the  clinical 
side  alone  which  informs  us  of  the  nature  of  the  pulmonary 
process. 

Abscess  of  the  Lung. — The  metastatic  or  pyemic  ab- 
scess following  infectious  diseases,  or  surgical  pyemas  will 
not  be  dealt  with:  nor  migratory  or  secondary  abscess  fol- 
lowing abscess  of  the  liver,  colon,  or  mediastinum.  Pneu- 
monic abscess  only  will  be  discussed. 

Abscess  of  the  lung  is  rare,  but  to  determine  it  radioscopic 
examination  is  of  unquestionable  service.  Clinically,  this 
diagnosis  is  almost  impossible  except  in  exceptional  cir- 
cumstances. Patients  who  are  affected  show  sometimes 
very  marked  intermittent  fever,  varied  thoracic  symptoms 
most  often  without  anything  definite,  and  a  somewhat 
serious  general  condition.  An  abscess  usually  follows  pneu- 
monia,   broncho-pneumonia,    or    bronchial    infection;    the 


Radiograph  26.    PSEUDO-PNEUMONIC  TRIANGLE  IN  A  TUBERCULOUS 

PATIENT 

The  upper  external  portion  of  the  right  lung  shows  an  opaque  triangular  shadow 
like  the  pneumonic  triangle  but  the  apex  of  the  lung  on  the  same  side  shows  clear 
and  dark  areas  side  by  side  which  suggest  cavities,  while  the  shadows  already  ex- 
tensive on  the  left  side  indicate  somewhat  advanced  bilateral  tuberculous  lesions. 


Radiograph  27.  PULMONARY  EMPHYSEMA 
Elongation  of  the  thorax  with  increase  of  clearness  of  the  pulmonary  fields,  en- 
largement and  elongation  of  the  hilus  shadow  made  more  apparent  by  the  clearness 
of  the  lungs.  Definite  and  deeper  areas  in  the  shadow  of  the  hilus  corresponding 
to  fibrous  or  calcareous  glands.  Diverging  lines  of  sclerosis,  starting  at  the  hilus 
and  spreading  out  like  a  fan  into  the  two  lungs;  enlargement  of  the  intercostal 
spaces;  elongation  of  the  heart  shadow  by  tension  on  the  mediastinum. 


ACUTE  INFECTIOUS  PULMONARY  PROCESSES    109 

thoracic  symptoms  are  ascribed  to'^the  primary  lesion  and 
do  not  attract  any  special  attention.  It  is  only  the  appear- 
ance of  a  vomica  followed  by  cavity  signs  which  makes  one 
think  either  of  an  abscess  or  of  an  encysted  pleurisy.  But 
the  vomica  may  be  absent,  and  in  any  case  it  is  preferable 
to  make  the  diagnosis  before. 

Bar j on  has  observed  two  cases  of  lung  abscess  and  thanks 
to  the  radioscopic  examination  he  could  determine  the  loca- 


FiG.  21.     ABSCESS  OF  LUNG 
Limited  shadow  in  the  postero-inferior  portion  of  the  right  lung 

tion  and  intervene  before  any  vomica  or  complications. 
The  first  of  these  patients  passed  as  tuberculous,  had  grown 
thin,  showed  marked  intermittent  fever,  coughed,  expecto- 
rated, and  at  first  sight  gave  the  impression  of  phthisis.  As 
he  lived  in  the  country,  no  laboratory  examination  could 
be  made — neither  examination  of  sputum  nor  tuberculin 
test.  Radioscopic  examination  of  this  patient  made  at 
home  by  means  of  a  portable  apparatus  showed  an  almost 
normal  clearness  of  the  pulmonary  areas  with  no  obscurity 
of  the  apices. 

In  the  middle  part  of  the  right  pulmonary  area  but  a  little 
nearer  the  base  was  an  abnormal  shadow,  oval  in  form,  the 
size  of  a  hen's  egg,  and  very  apparent  although  its  contours 
were  a  little  diffuse.    This  shadow  had  no  relation  either  to 


110  RADIO-DIAGNOSIS:  LUNGS 

the  hilus,  the  median  shadow,  or  the  wall.  It  seemed  inde- 
pendent of  the  pleura  and  appeared  in  the  middle  pulmon- 
ar}'  parenchyma.  The  oblique  and  transverse  examinations 
showed  that  the  relation  was  closer  to  the  posterior  than  to 
the  anterior  wall.  Bar j on  was  able  to  advise  a  posterior 
approach  to  the  affected  area  and  to  determine  the  inter- 
costal space  where  the  incision  ought  to  be  made.  Surgical 
intervention  demonstrated  the  value  of  these  deductions 
and  brought  to  light  a  somewhat  deep  pulmonary  abscess, 
which  was  emptied  and  drained.    The  patient  recovered. 


Fig.  22.     ABSCESS  OF  LUNG 
Rather  extensive  opaque  shadow  situated  in  the  inferior  portion  of  the  right 
pulmonary  field  on  the  internal  border  and  in  the  anterior  portion 

The  second  case  was  a  man  forty-six  years  old  who,  follow- 
ing herpetic  sore-throat  and  a  series  of  mouth  herpes,  had 
shown  somewhat  serious  thoracic  conditions.  Stethoscopic 
examination  made  at  intervals  was  negative.  The  tempera- 
ture had  varied  for  three  months  between  38°  and  39. 5""  C. 
Radioscopic  examination  showed  a  very  opaque  and  some- 
what extensive  abnormal  shadow,  in  the  anterior,  lower 
and  internal  parts  of  the  pulmonary  field. 

This  shadow  continued  almost  without  a  line  of  demarca- 
tion the  median  shadow  and  descended  as  far  as  the  dia- 
phragm.   In  this  case  it  was  impossible  to  tell  whether  the 


ACUTE  INFECTIOUS  PULMONARY  PROCESSES     111 

affected  area  was  interpulmonary  or  whether  it  was  an 
encysted  pleurisy.  Surgical  intervention  being  indicated 
as  in  the  other  case,  it  was  practised  some  days  afterward 
and  showed  that  it  was  a  lung  abscess  and  not  encysted 
pleurisy.    In  this  case  also  the  result  was  excellent. 

These  two  cases  are  sufficient  to  show  the  important  part 
played  by  radioscopic  examination  in  abscess  of  the  lung, 
as  also  in  all  pleuro-pneumonia  localizations  in  which  surgi- 
cal intervention  is  indicated. 


Fig.  23.     CENTER    OF    PLEURO-PULMONARY    GANGRENE    OF    THE 
RIGHT  BASE  WITH  HYDROPNEUMOTHORAX 

Pulmonary  Gangrene. — Pulmonary  gangrene  comes 
clearly  into  the  category  of  thoracic  affections  where  radio- 
logical examination  ought  never  to  be  neglected.  Un- 
doubtedly clinical  diagnosis  is  easier  on  account  of  the  char- 
acteristic odor  of  the  breath,  which  attracts  attention,  but 
it  is  useful  to  be  able  to  determine  the  location  and  extent 
of  the  lesions  so  as  to  indicate  treatment.  The  radioscopic 
pictures  vary  according  to  the  clinical  form  which  the  gan- 
grenous process  assumes.  The  principal  forms  are:  bron- 
chial, pleural,  pneumonic.  It  is  the  last  two  which  offer 
most  interest  because  surgical  intervention  is  seldom  indi- 
cated in  the  bronchial  form,  while  it  may  become  urgent 
in  the  other  two.    The  part  of  the  radiologist  is  to  furnish 


112  RADIO-DIAGNOSIS:  LUNGS 

to  the  surgeon  all  useful  information,  either  as  to  when  to 
intervene,  or  as  to  how  to  approach  the  gangrenous  center. 

Beclere  and  Guisez  have  determined  by  radioscopic  ex- 
amination and  the  radiograph  the  site  of  a  gangrenous 
center  located  in  the  lower  two-thirds  of  the  right  pulmon- 
ary field.  It  was  shown  by  the  characteristic  image  of  a 
hydropneumothorax.  Examination  under  different  condi- 
tions showed  that  the  central  cavity  was  equally  distant 
from  the  anterior  and  posterior  surfaces,  consequently 
difficult  to  approach.  This  information  made  treatment 
by  large  injections  of  antiseptic  oil  preferable  to  uncertain 
surgical  intervention.  This  treatment  was  completely 
successful.  In  three  cases  shown  by  Frankel,  operation  on 
the  contrary  was  decided  upon,  which  also  was  followed 
by  good  results. 

IMore  recently,  Henri  Beclere  was  able  to  localize  a  gan- 
grenous center  in  the  region  of  the  hilus  and  to  indicate 
a  dorsal  course.  This  allowed  Lejars  to  come  at  once  upon 
the  cavity,  which  was  emptied  and  drained. 

Quite  lately,  in  a  patient  of  Dr.  Gallavardin's  a  center  of 
pulmonary  gangrene  was  localized  at  the  right  base  and 
seen  on  the  screen  as  a  very  clear  hydropneumothorax. 


CHAPTER  III 
CHRONIC  PULMONARY  PROCESSES 

PULMONARY  EMPHYSEMA.— Pulmonary  emphy- 
sema may  be  localized  in  a  portion  of  the  pulmonary 
parenchyma.  It  is  most  often  either  at  the  apex  or  on  the 
anterior  surface  of  the  lung  and  in  this  case  it  scarcely  ever 
gives  a  radioscopic  picture.  It  is  secondary  to  other  lesions — 
in  particular,  to  tuberculosis,  which  often  goes  unnoticed  on 
account  of  the  increase  in  clearness  due  to  the  distended 
emphysematous  alveoli. 

Generalized  emphysema  is  quite  different  and  is  ordi- 
narily seen  on  the  radioscopic  screen  by  a  succession  of 
important  characteristic  changes:  exaggerated  clearness  of 
the  pulmonary  fields,  disappearance  of  the  shadow  on  the 
sides,  deformation  and  enlargement  of  the  thorax,  appear- 
ance of  abnormal  shadows. 

Exaggerated  clearness  of  the  pulmonary  fields  is  total 
and  permanent.  While  in  a  normal  subject  the  difference 
in  clearness  is  considerable  between  inspiration  and  ex- 
piration, in  the  emphysematous  it  is  immaterial.  In  the 
normal  lung,  in  inspiration  the  clearness  increases  in  inten- 
sity, especially  toward  the  bases,  and  in  forced  inspiration 
these  are  lighted  up  in  a  quite  remarkable  manner.  In 
expiration,  on  the  contrary,  in  proportion  as  the  air  is  driven 
from  the  alveoli,  the  pulmonary  fields  become  obscure  and 
take  on  a  diffuse,  grayish  tint.  In  forced  expiration  there  is 
difficulty  in  distinguishing  the  convexity  of  the  diaphragm 
from  the  outline  of  the  heart. 

In  the  emphysematous,  where  the  lung  is  distended  with 
air  and  the  alveoli  have  lost  all  elasticity  and  become  unable 
to  expel  the  air  they  contain,  there  is  no  longer  any  differ- 

113 


114  RADIO-DIAGNOSIS:  LUNGS 

ence  in  clearness  between  inspiration  and  expiration  be- 
cause in  both  the  kuig  remains  inflated  with  air. 

Deformation  of  the  thorax  in  the  emphysematous  is 
characterized  radiologically  by  an  important  elongation. 
The  thoracic  cavity  appears  increased  vertically;  the  ribs 
are  more  elevated,  more  horizontal  and  in  consequence  of 
this  change  of  direction,  the  intercostal  spaces  are  enlarged. 

There  results  at  the  same  time  a  lowering  of  the  diaphragm 
and  the  arch  becomes  flattened.  The  convexity  of  the  dome 
is  diminished,  the  depth  of  the  costodiaphragmatic  sinuses 
is  reduced,  as  well  as  the  extent  of  the  respiratory  move- 
ments. The  lowering  of  the  diaphragm  causes  a  tension 
on  all  the  organs  of  the  mediastinum  and  on  the  heart  which 
appears  more  vertical. 

Abnormal  shadows  appear,  ordinarily  small  in  area  but 
made  more  visible  by  the  increased  clearness  of  the  pul- 
monary fields.  These  shadows  are  in  relation  to  the  primary 
or  superadded  lesions,  for  it  is  admitted  more  and  more  that 
emphysema  is  only  the  result  of  older  inflammatory  processes. 

Patients  often  show  cicatrices  of  old  healed  lesions,  affect- 
ing by  preference  the  apices,  sometimes  as  small  defined 
shadows  corresponding  to  old  tuberculous  cicatrices,  some- 
times by  diffuse  obscureness  due  to  a  certain  amount  of 
apical  sclerosis.  Often  there  is  at  the  same  time  an  enlarge- 
ment and  an  elongation  of  the  hilus  shadow.  This  anomaly 
is  caused  by  the  existence  of  small  inflammatory  or  sclerotic 
nodes  associated  with  the  diffuse  sclerosis  of  the  peribronchial 
tissue  radiations.  There  are  clearly  seen  upon  the  screen 
and  on  the  radiographic  plate  dark,  diverging  radiations 
arising  in  the  shadow^  of  the  hilus  and  gradually  shading 
into  the  clear  lung.  There  is  often  seen  also  diminution  in 
the  shadow  of  the  ribs  which  become  less  visible;  their  con- 
tours are  more  shaded  and  as  if  surrounded  by  a  sort  of  halo 
because  of  the  increase  in  thoracic  clearness. 

Pulmonary  Sclerosis. — In  contrast  to  emphysema, 
sclerosis  is  anatomically  a  thickening  of  the  pulmonary 
parenchyma  and  contraction  of  the  lung,  and  consequently, 


Radiograph  28.  TUBERCULOSIS  OF  THE  LEFT  LUNG  REMAINING 
UNILATERAL  FOR  EIGHT  YEARS.  LARGE  CAVITIES  OF  THE 
APEX.  SCLEROSIS  WITH  CONSEQUENT  PULMONARY  RETRAC- 
TION. INSPIRATORY  DISPLACEMENT  OF  THE  MEDIASTINUM 
TO  THE  LEFT.  MORE  RECENT  LESIONS  IN  THE  RIGHT  APEX 
Total  obscurity  of  the  left  hemithorax  with  large  clearer  zones  in  the  upper  half 

(cavities) . 


Radiograph  29.  INCIPIENT  TUBERCULOSIS 
Clinical  signs  more  important  than  radioscopic  signs.  Woman  of  eight  months 
pregnancy.  Deformity  of  the  thorax,  ribs  and  clavicles.  Clearness  of  the  apices 
quite  well  retained.  Obscure,  diverging  lines  from  the  hilus  region  on  both  sides 
and  spreading  out  like  a  fan  into  the  pulmonary  fields.  Clinical  examination — 
at  the  right  apex  diminution  of  sonorousness.  Increase  of  fremitus,  sensitiveness 
on  percussion;  great  diminution  of  vesicular  sound.  Diffuse  bronchitis  over  the 
entire  right  lung;  no  loose  rales.  At  the  right  apex  the  clinical  signs  are  more  im- 
portant than  the  radioscopic. 


CHRONIC  PULMONARY  PROCESSES  115 

from  a  radiological  point  of  view,  is  seen  as  a  decrease  in 
clearness  and  reduction  of  the  pulmonary  field.  When  local, 
sclerosis  is  seen  on  the  screen  as  a  diffuse,  well  defined  ob- 
scurity; when  generalized,  it  is  characterized  by  total 
diminution  in  the  clearness  of  the  pulmonary  fields  and  the 
invariability  of  the  diameters  of  the  thorax  in  inspiration 
and  expiration. 

In  the  case  of  unilateral  sclerosis,  Beclere  has  drawn  atten- 
tion to  an  important  radioscopic  sign  consisting  of  the  dis- 
placement of  the  mediastinum  on  the  diseased  side  during 
deep  inspiration.  The  unaffected  lung  which  has  retained 
its  elasticity  takes  in  a  greater  amount  of  air,  gives  a  greater 
pressure  and  more  considerable  volume.  Therefore  it  presses 
considerably  upon  the  mediastinum  and  displaces  it  to  its 
own  advantage.  Unilateral  sclerosis  may  be  localized  in 
one  lobe:  either  in  the  upper  lobe,  which  is  most  frequent 
when  it  succeeds  an  acute  lobar  pneumonia,  or  in  the  lower 
lobe,  when  it  is  the  result  of  a  series  of  congestive  and 
oedematous  attacks  like  that  seen  in  certain  cardiac  cases. 

Circumscribed  scleroses  are:  cicatricial  sclerosis,  seen  as 
limited  shadows  which  serve  to  establish  retrospective 
diagnosis  of  the  primary  lesions  which  have  caused  them; 
abscess  of  the  lung;  areas  of  pulmonary  gangrene;  old 
tuberculous  lesions;  hydatid  cyst;  infarct,  etc. 

Pneumoconioses,  and  particularly  anthracosis,  which  is 
the  most  important  form,  should  be  classed  with  pulmonary 
sclerosis,  but  no  special  radiological  study  apparently  has 
been  made  on  the  subject. 

Atelectasis. — ^Atelectasis  is  a  particular  condition  of 
the  lung  arising  from  the  disappearance  of  air  in  the  alveoli. 
There  results  radiologically  a  more  considerable  opacity  of 
the  atelectasized  area  in  comparison  with  the  parts  which 
have  retained  their  entire  permeability. 

Atelectasis  may  be  total  or  partial.  Total  atelectasis 
occurs  under  two  forms:  in  the  new-born,  where  breathing 
has  not  occurred,  it  is  bi-lateral;  in  the  patient  with  a  well 
established  artificial  pneumothorax,  it  is  unilateral. 


116  RADIO-DIAGNOSIS:  LUNGS 

In  the  new-born  the  radiological  appearance  of  the  lungs 
changes  totally  accordmg  to  whether  one  has  to  do  with 
lungs  which  have  never  functioned  or  with  those,  on  the 
contrary,  that  have  undergone  alveolar  distention  following 
penetration  of  air.  It  has  been  suggested  to  use  in  legal 
medicine  radiographs  of  the  new-born  to  determme  whether 
the  child  has  or  has  not  breathed.  According  to  Vaillant, 
the  radiographic  appearance  of  the  lungs,  stomach  and  in- 
testines is  entirely  characteristic  in  the  child  which  has  lived. 
None  of  these  organs  is  visible  in  a  child  that  has  not  breathed 
at  all.  According  to  Bouchacourt,  if  air  is  forced  into  the 
child  through  the  mouth  instead  of  its  having  breathed 
spontaneously,  gas  is  found  in  the  stomach  and  lungs  but 
there  is  never  dilatation  of  the  pulmonary  apices.  These 
radiological  findings  have  been  disputed  by  Beclere,  Menard, 
and  later  by  Bordas,  so  that,  from  a  purely  legal  point  of 
view,  only  a  relative  value  can  be  attached  to  these  findings. 

Complete  unilateral  atelectasis  occurs  through  the  opera- 
tion of  Forlanini,  or  artificial  pneumothorax.  When  inter- 
vention is  entirely  successful,  and  nothing  interferes  with 
complete  collapse  of  the  lung,  this  organ  retracts,  the  air  is 
expelled.  Atelectasis  then  occurs  and  the  lung  becomes 
much  more  opaque  to  Roentgen  rays.  It  becomes  much 
more  clearly  visible  on  the  radioscopic  screen.  Its  contours 
are  raised  on  the  gaseous  clearness  of  the  inflated  thoracic 
cavity  and  make  it  appear  like  a  narrow  band  superimposed 
on  the  median  shadow. 

Partial  atelectasis  is  most  often  the  result  of  compression. 
It  usually  follows  pleuritic  effusion  and  is  localized  in  the 
lower  parts  of  the  lung.  Radiologically,  it  appears  as  a 
diffuse  obscurity  in  addition  to  that  produced  by  exudates 
and  thickening  of  the  pleura.  It  is  also  seen  in  the  left  base 
in  patients  with  marked  hypertrophy  of  the  heart  following 
cardiopathy,  nephritis,  pericardial  adhesions.  These  light 
shadows,  diffuse  and  poorly  outlined,  show  absolutely  noth- 
ing characteristic  from  a  radiological  point  of  view,  but  are 
a  help  in  confirming  the  clinical  diagnosis. 


CHAPTER  IV 
PULMONARY  TUBERCULOSIS 

THE  radiological  study  of  pulmonary  tuberculosis  is  of 
great  interest.  This  disease  represents  almost  the 
whole  of  pathology  in  its  innumerable  forms,  variations  of 
onset,  development  and  in  its  many  complications. 

Radiological  examination  will  be  of  value  if  it  can  help 
detect  latent  forms  of  tuberculosis  which  show  no  clinical  or 
stethoscopic  signs.  The  recognition  of  these  cases  makes 
easy  the  interpretation  of  certain  diagnostic  signs  otherwise 
difficult  for  even  the  best  informed  physician.  Its  part  will 
be  more  important  still  if  we  can,  in  certain  cases,  find  the 
lesions  at  their  very  beginning  and  pronounce  an  earlier 
diagnosis  which  will  make  treatment  infinitely  more  effica- 
cious and  increase  greatly  the  chances  of  cure.  Finally,  its 
value  will  not  be  insignificant  if  it  confirms  the  clinical 
diagnosis  and  allows  us,  on  the  other  hand,  to  separate  from 
this  confused  mass  of  patients  the  pseudotuberculous.  Its 
worth  will  be  recognized  also  if  it  establishes  in  the  true 
types  an  exact  topography  of  the  lesions,  follows  their  devel- 
opment, gives  information  on  the  innumerable  complications 
which  may  arise,  and  furnishes  as  well  useful  indications  for 
Forlanini's  treatment  in  those  who  are  beyond  purely  med- 
ical treatment. 

It  is  not  to  be  assumed  that  the  radiological  diagnosis 
of  tuberculosis  is  to  displace  clinical  examination  and  aus- 
cultation. Radiological  examination  may  often  be  useful, 
but  may  often  give  no  indication.  It  is  not  infallible.  Cer- 
tain light,  disseminated  lesions,  insufficient  to  change  the 
density  or  the  elasticity  of  the  parenchyma  may  perfectly 
well  pass  unnoticed.  The  radiologist  when  not  taking  into 
account  clinical  methods  of  examination  may  very  well 

117 


118  RADIO-DIAGNOSIS:  LUNGS 

declare  a  case  of  incipient  tuberculosis  with  apparent  signs 
on  auscultation  to  be  non-tuberculous.  But  the  same  is 
true  of  the  physician  who  has  relied  wholly  on  clinical 
methods. 

That  is  to  say,  radiological  examination  is  open  to  the 
same  mistakes  as  all  other  methods  of  investigation,  but 
there  are  cases  where  radiological  examination  may  prove 
of  value,  so  that  a  physician  is  unwise  to  deprive  himself 
of  the  information  obtained  from  this  new  source.  To  make 
useful  the  radioscopic  study  of  pulmonary  tuberculosis  it 
is  not  necessary  to  study  separately  each  of  the  many  forms 
which  are  met  with  in  the  clinic.  Three  distinct  groups 
only  will  be  considered : 

a.  Pulmonary  tuberculosis  without  clinical  or  stetho- 
scopic  signs.    (Latent  forms.) 

b.  Pulmonary  tuberculosis  with  clinical  signs  but  stetho- 
scopic  signs  negative,  doubtful,  or  very  limited.  (Early 
forms:  Period  of  incubation.    Miliary.) 

c.  Advanced  pulmonary  tuberculosis  with  evident  clini- 
cal and  stethoscopic  signs.  (Chronic  pulmonary  tuber- 
culosis with  its  many  forms.) 

Pulmonary  Tuberculosis  without  Clinical  or  Stetho- 
scopic Signs. — (Latent  forms.)  The  latent  forms  of  pul- 
monary tuberculosis  are  common.  As  they  give  no  chest 
symptoms,  either  physical  or  clinical,  they  often  remain 
undetected. 

Sometimes  these  latent  forms,  instead  of  giving  respiratory 
or  chest  symptoms,  affect  instead  quite  another  organ. 
Sometimes  the  general  health  alone  is  affected.  Patients 
grow  steadily  thin,  lose  strength  and  appetite  without 
apparent  cause.  Otherwise  there  is  neither  cough,  expectora- 
tion, nor  shortness  of  breath.  Auscultation  of  the  chest 
does  not  reveal  any  change  of  the  vesicular  sounds.  At 
times  the  disease  takes  the  form  of  anemia  or  of  chlorosis, 
evident  by  increased  pallor,  palpitation,  shortness  of  breath, 
and  especially  nervous  condition.  At  other  times  the  diges- 
tive tract  is  affected,  as  evidenced  by  dyspepsia  with  a 


Radiograph  36.     BILATERAL     PULMONARY      TUBERCULOSIS     WITH 
RAPID  PROGRESS 
No.  227.     L.  D.     Female,   14  years  old.     Chronic  active  bilateral  pulmonary 
tuberculosis.     Typical  clinical  history  and  physical  findings:  Dullness.     Rales. 


Radiograph  37.  EXTENSIVE  TUBERCULOSIS  OF  THE  RIGHT  LUNG 
WITH  CAVITIES  AT  THE  APEX 
Total  obscurity  of  entire  hemithorax  with  clear  zones  (hardly  visible  on  examina- 
tion) at  the  apex.  At  the  left,  extensive  shadow  at  hilus  region  -n-ith  scattered 
mottling.  Clinical  signs — cavernous  respiration  at  the  right  apex  very  extensive. 
In  the  lower  half  abundant,  moist,  gurgling  rales,  purulent  expectoration,  numerous 
Koch  bacilli.  Onset  nine  years  ago  with  hemoptysis.  At  present,  bilateral  lesions; 
infiltration  in  mass  of  the  whole  right  side  with  disintegration  and  cavities.  Partial 
dextrocardia. 


PULMONARY  TUBERCULOSIS  119 

heavy  feeling,  slow,  painful  digestion,  loss  of  appetite,  some- 
times vomiting,  continual  loss  of  weight.  At  times,  too, 
these  patients  appear  like  neurasthenics  in  a  state  of  lassi- 
tude, depression  and  great  discouragement.  Unless  these 
facts  were  as  well  known  as  they  are  now,  nothing  would 
attract  one's  attention  to  pulmonary  tuberculosis,  as  the 
most  careful  auscultation  often  remains  negative.  The 
clinician  in  these  cases  has  often  to  resort  to  other  methods 
for  information  and  among  them — aside  from  the  valuable 
laboratory  tests  (serum,  ophthalmic,  and  skin  reaction) — 
radioscopic  examination  should  naturally  be  included. 

There  are  a  certain  number  of  latent  forms  of  tuberculosis 
which  give  absolutely  no  signs,  although  those  affected 
appear  in  perfect  health.  They  are  the  old,  cured  tubercu- 
lous cases  with  well  defined  lesions,  the  progress  of  which 
has  gone  on  often  entirely  unnoticed.  These  facts  have 
been  well  known  ever  since  Laennec  demonstrated  the  fre- 
quency of  these  cicatricial  lesions  in  autopsies.  All  clinicians 
have  observed  them,  either  under  the  form  of  fibrous  cica- 
trix, cretaceous  tubercle,  small  caseous  centers  enclosed 
in  a  fibro-calcareous  covering,  or  under  the  form  of  glands 
having  undergone  caseous  or  calcareous  degeneration.  All 
these  lesions,  clinically  absent,  may  be  demonstrated  by 
radioscopic  examination,  which  shows  the  existence  of  a 
previous  attack  of  tuberculosis  until  then  completely 
ignored. 

Pulmonary  tuberculosis,  often  appearing  slight  and  in- 
cipient in  a  patient  will  be  proved  by  radioscopic  examina- 
tion to  be  more  extensive  and  secondary  to  a  previous  attack. 
The  frequency  of  radioscopic  changes  in  pulmonary  pictures 
of  hospital  cases  is  very  great.  Kelsch  and  Boinon,  in  a 
military  hospital  accepting  only  selective  cases  of  young 
men,  found  these  pulmonary  changes  51  times  out  of  124 
patients  examined,  that  is,  41  to  100.  They  do  not  assert 
that  all  these  anomalies  are  of  a  tuberculous  nature,  but 
undoubtedly  a  good  number  of  them  must  be.  In  a  civil 
hospital  receiving  patients  of  all  ages  with  a  more  severe 


120  RADIO-DIAGNOSIS:  LUNGS 

pathological  past  the  frequency  of  these  anomalies  is  still 
more  marked. 

The  study  of  these  abnormal  shadows  either  at  the  apex 
or  in  a  limited  portion  of  the  lung,  in  the  hilus  area,  inter- 
lobar fissures,  and  costodiaphragmatic  sinuses  will  often 
assist  us  in  detecting  these  latent  forms  and  in  ascribing  to 
their  true  cause  diseases  which  from  the  abnormal  appear- 
ance would  have  been  difficult  of  interpretation. 

Pulmonary  Tuberculosis  w^th  Clinical  Signs  but 
Stethoscopic  Signs  Negative,  Doubtful  or  very  Lim- 
ited.— (Early  forms.  Period  of  incubation.  Miliary.) 
This  class  includes  all  patients  w^ho  show  clinical  signs, 
functional  troubles  affecting  the  respiratory  tract,  but 
whom  the  negative  or  doubtful  stethoscopic  examination 
will  not  allow  us  to  class  as  tuberculous,  such  as  young 
people  who  grow  thin,  have  intermittently  a  small,  dry 
cough  without  expectoration,  which  is  commonly  classed 
as  a  nervous  cough.  They  easily  get  out  of  breath  and  on 
the  least  exertion  have  an  increased  pulse  rate. 

There  are,  too,  habitual  coughers,  who  in  general  good 
health,  have  so-called  repeated  prolonged  colds,  grippe  in 
all  its  forms  without,  how^ever,  having  any  precise  localiza- 
tion discernible  on  auscultation. 

There  are  the  incipient  tuberculous  cases  with  doubtful 
stethoscopic  signs  or  intermittent  signs  appearing  and  dis- 
appearing from  day  to  day,  passing  from  the  right  to  the 
left  apex,  consisting  of  slight  changes  in  the  vesicular  sounds 
without  abnormal  sounds  or  rales.  In  all  these  patients 
attention  is  drawn  to  the  respiratory  tract,  but  one  cannot 
state  that  it  is  tuberculosis.    These  are  doubtful  cases. 

Careful  radiological  examination  here  may  be  useful  and 
help  in  dispelling  doubt  one  way  or  another.  Examination 
must  be  made  methodically  and  should  include  the  apices, 
hilus,  interlobes,  form  and  dimensions  of  the  thorax,  direc- 
tion and  displacement  of  the  ribs,  and  respiration. 

Examination  of  the  apices. — This  examination  ought  to 
be  made  with  most  minute  care  and  after  taking  all  possible 


PULMONARY  TUBERCULOSIS  121 

precautions.  Both  the  radioscope  and  the  radiograph  should 
be  used. 

Radioscopy. — Radioscopic  examination  of  the  apices  ought 
to  be  made  under  the  best  possible  conditions  of  light,  with 
a  well  regulatable  tube,  so  that  the  quality  of  the  rays  can 
be  varied  in  such  a  manner  as  to  get  every  detail  of  shadow. 
Normally,  the  apices  are  less  clear  than  the  bases;  the  bony 
rigid  cavity  in  which  the  lungs  are  enclosed  hinders  expan- 
sion of  the  upper  part  so  that  the  air  penetrates  in  smaller 
quantity  and  their  clearness  suffers  thereby.  However, 
their  transparency  remains  sufficient  for  the  contour  of  the 
ribs  and  clavicle  to  stand  out  clearly.  Apart  from  this 
pathological  state,  it  is  very  important  to  know  that  the 
clearness  of  the  apices  varies  exceedingly  with  individuals. 
Thin  and  poorly  nourished  patients  show  a  very  perceptible 
transparency  of  the  apices,  while  in  obese  and  very  muscular 
patients  the  apices  become  obscured  and  uniformly  gray. 
It  is  not  necessary,  then,  to  attach  absolute  value  to  a 
diminution  of  equal  and  symmetrical  clearness  on  both  sides. 
A  comparison  of  the  pictures  of  the  two  apices  taken  from 
the  anterior  as  well  as  from  the  posterior  position  is  necessary, 
and  to  do  it  well  it  is  essential  to  limit  the  light  exactly  to  the 
region  of  the  apex  by  means  of  a  lead  diaphragm. 

Far  more  important  is  the  ascertaining  of  a  unilateral 
obscurity  resulting  from  this  comparative  study;  yet  even 
in  this  case,  conclusions  must  not  be  hastily  drawn. 

First  of  all,  it  should  be  determined  whether  this  unilateral 
obscurity  is  indeed  of  pulmonary  origin.  To  do  so  the  patient 
must  be  examined  to  see  whether  this  lack  of  clearness  may 
not  be  caused  by  an  anomaly  of  the  skeleton,  a  malformation 
of  the  clavicle,  or  scapula,  or  by  a  scoliosis.  Sub-clavicular 
fossae  must  be  carefully  palpated  to  see  whether  some  gland 
may  not  be  the  cause  of  this.  The  thyroid  gland  ought  to 
be  examined,  as  a  goitre  scarcely  apparent  is  enough  to  pro- 
duce the  difference  in  clearness  of  the  apices.  In  fact,  the 
neck  ought  to  be  carefully  gone  over.  When  no  other  ex- 
ternal cause  is  a  factor,  use  should  be  made  of  the  clinical 


122  RADIO-DIAGNOSIS:  LUNGS 

information.  If  stethoscopic  examination  is  negative,  no 
conclusion  can  be  drawn,  but  if  some  doubtful  or  intermittent 
signs  are  heard,  it  is  necessary  to  compare  the  findings.  If 
they  do  not  agree,  if  the  doubtful  auscultatory  signs  appear 
on  the  right  side,  for  example,  while  the  radioseope  shows  a 
diminution  of  clearness  of  the  left  apex,  one  must  be  careful 
in  drawing  conclusions.  If  the  findings  are  alike  in  the  two 
methods,  the  probabilities  will  become  almost  a  certainty. 

In  this  case  only  a  slight  difference  of  shade,  almost  doubt- 
ful, exists  between  the  two  apices.  If  the  shadow  is  much 
more  marked,  not  homogeneous,  and  darker  spots  appear 
on  the  general  gray  shade,  the  radioscopic  information  in 
itself  takes  on  greater  value.  But  it  may  be  that  the  radio- 
scopic examination  shows  nothing,  that  the  most  careful 
study  discloses  no  appreciable  difference  between  the  clear- 
ness of  the  two  apices.  Even  then  the  lungs  cannot  be  de- 
clared sound,  for  there  may  perfectly  well  exist  questionable 
lesions,  disseminated  tubercles,  incapable  separately  of  fur- 
nishing a  radioscopic  picture  appreciable  to  the  eye.  But 
the  radiograph,  however,  is  still  useful  in  completing  this 
study. 

Radiography. — The  radiograph  gives  greater  depth  to  the 
picture  than  does  the  radioseope.  The  very  perceptible 
decrease  of  sharpness  in  the  radioseope  makes  it  impossible 
for  us  to  see  on  the  screen  the  fine  detail  of  structure  and 
half-tones  which  we,  on  the  contrary,  easily  read  on  the 
negative  examined  in  full  light.  For  a  long  time  the  radio- 
graph was  neglected  in  studying  the  lungs  on  account  of  the 
technical  difficulties,  the  principal  of  which  was  the  length 
of  exposure.  To-day  in  well  equipped  laboratories  one  can 
reduce  the  length  of  time  for  taking  radiographs  to  the  frac- 
tion of  a  second,  especially  with  the  aid  of  the  new  inten- 
sifjdng  screens.  In  this  way  immobilization  of  the  lung  is 
complete  and  pictures  are  obtained  in  which  the  finest  detail 
in  structure  appears.  Thus  very  small  initial  lesions  which 
it  would  be  impossible  to  see  on  the  radioscopic  screen  are 
demonstrated. 


Radiograph  30.     INCIPIENT     TUBERCULOSIS.     RADIOSCOPIC     SIGNS 
MORE  IMPORTANT  THAN  THE  CLINICAL 

An  opaque,  rounded  shadow  approaches  on  the  right  the  median  shadow  above 
the  auricle.  Obscurity  of  the  right  apex  already  well  marked.  Abnormal  shadow.s 
are  present  in  the  upper  half  of  the  pulmonary  fields  on  both  sides.  Clinical  signs 
very  slight  and  limited  to  the  right  apex.  No  modification  of  sonorousness.  Slight 
increase  in  fremitus  and  diminution  of  the  vesicular  sound.  Some  small,  inter- 
mittent rales  after  coughing,  in  the  sub-spinous  fossa.  Nothing  on  the  left.  The 
radiograph  indicates  tuberculosis  of  the  tracheo-bronchial  glands  on  the  right. 
A  very  appreciable  obscurity  of  the  right  apex  and  quite  extensive  shadows  in 
both  lungs. 


Radiograph  3L     "TUBERCULOSE    SCISSURALE"    ON    THE    RIGHT   IN 

A  CHILD 

Transverse  opaque  band  at  the  level  of  the  right  interlobe.  The  lower  border 
of  this  shadow  is  clearly  defined  while  the  upper  border  is  blurred  and  indistinct. 
Pulmonary  tuberculosis  is  well  developed  especially  on  the  side  of  the  upper  lobe. 


PULMONARY  TUBERCULOSIS  123 

To  obtain  good  results  a  radiograph  of  the  apices  should 
be  taken  and  not  of  the  whole  thorax.  A  cylindrical  cone 
and  tube  not  too  hard  (G°  B.)  will  give  more  detail.  The 
patient  should  be  on  his  back  and  well  immobilized  with  the 
radiographic  frame  beneath  the  shoulders  so  that  they  are 
symmetrical  and  in  close  contact  with  the  frame.  The 
negatives  obtained  with  these  precautions  show  the  slightest 
abnormal  shadows  and  the  exact  structure  of  the  apices. 

Examination  of  the  hilus. — ^After  the  study  of  the  apices, 
attention  should  be  directed  to  the  hilus  of  the  lungs.  In 
studying  normal  pictures  it  has  been  shown  that  the  shadow 
of  the  hilus  is  somewhat  crescent  shaped  and  elongated, 
situated  at  the  edge  of  the  median  shadow  and  separated 
from  it  by  a  narrow  band.  The  convex  side  of  the  crescent 
is  turned  towards  the  median  shadow.  The  two  points  are 
unequal  in  length.  The  upper  point  is  short,  while  the  lower 
one  is  longer  and  projects  into  the  lower  third  of  the  pul- 
monary field.  This  lower  horn  is  visible  only  on  the  right, 
while  on  the  left  it  is  covered  by  the  cardiac  shadow.  This 
hilus  shadow  is  distinguished  clearly  in  the  normal  and  al- 
ways remains  somewhat  light.  In  tuberculous  patients  the 
shadow  of  the  hilus  is  very  often  modified  in  an  early  stage. 
There  are  even  cases  in  which  tuberculosis  of  the  hilus  pre- 
cedes pulmonary  tuberculosis.  This  mode  of  onset  in  chil- 
dren is  admitted  by  a  large  number  of  clinicians.  In  adults 
it  is  much  disputed.  Rieder  and  Rosenthal  of  Munich  have 
drawn  attention  since  1908  to  the  frequency  of  this  mode  of 
onset. 

Whatever  opinion  may  be  held  on  this  subject,  radiol- 
ogists generally  agree  upon  this  one  fact,  that  the  hilus 
shadow  is  abnormal  at  an  early  stage  in  tuberculosis.  This 
condition  is  seen  by  an  increased  opacity  of  the  shadow, 
which  becomes  more  visible  and  less  homogeneous,  by  the 
disappearance  of  the  narrow  band  of  light  separating  it  from 
the  median  shadow,  by  its  central  enlargement  and  the 
elongation  of  the  points,  which  cause  the  crescent  form  to 
disappear. 


124  RADIO-DIAGNOSIS:  LUNGS 

The  deformation  is  not  regular ;  it  predominates  sometimes 
in  the  upper  point,  sometimes  in  the  lower.  These  hilus 
changes  have  a  very  great  value.  Undoubtedly  their  pres- 
ence does  not  signify  absolutely  that  tuberculosis  is  present. 
]\Iany  bronchial  and  peribronchial  inflammations,  non- 
tuberculous,  may  produce  them.  It  is  commonly  found  in 
children,  following  whooping-cough,  measles,  or  simply 
grippe.  It  may  appear  in  the  adult  in  a  number  of  affections 
involving  the  mediastinum,  oesophagus,  or  even  the  stomach. 
It  has  not  anything  pathognomonic,  but  its  occurrence  in  a 
patient  with  suspected  tuberculosis  has  a  very  great  value. 
Radioscopic  examination,  principally  in  the  frontal  position, 
is  sufficient  in  general  to  show  them,  but  the  radiograph 
establishes  this  picture  for  a  more  careful  study  of  their 
exact  form,  structure,  and  the  direction  of  inflammatory 
irradiations  which  may  be  produced  on  the  side  of  the  lung. 

Examination  of  the  interlobes. — It  is  important  to  ascertain 
carefully  the  condition  of  the  interlobes  in  patients  suspected 
of  tuberculosis.  Often  the  onset  occurs  in  an  interlobar 
fissure  and  then  extends  to  the  corticalis  of  the  adjacent 
pulmonary  lobes  ('Huberculose  scissurale").  The  affection 
in  this  case  seems  to  begin  in  the  middle  portion  of  the  lung. 
This  mode  of  onset  is  rather  common.  Bar j  on  and  P^hu  have 
often  met  with  it  in  children.  Barjon  has  also  seen  it  several 
times  in  adults. 

A  somewhat  opaque,  obscure  band  is  shown  by  radio- 
scopic examination  to  cut  transversely  the  hemithorax  in 
its  entire  width  at  the  level  of  the  interlobe.  This  band  is 
more  or  less  wide  according  as  the  pulmonary  lesion  is  more 
or  less  extensive,  the  extension  taking  place  on  both  sides 
of  this  band  into  the  adjacent  lobes.  The  more  the  lung  is 
affected,  the  lighter  the  contours  of  the  band  become. 
Diagnosis  of  interlobar  pleurisy  is  made  by  radiological 
and  clinical  methods.  The  radioscopic  picture  is  less  dis- 
tinct and  does  not  show  the  distended  edges  clearly  sep- 
arated from  the  interlobar  mass.  Clinically  the  develop- 
ment of  the  ''tuberculose  scissurale"  is  somewhat  insidious. 


PULMONARY  TUBERCULOSIS  125 

Often  it  gives  no  stethoscopic  evidence,  nor  the  high  tempera- 
ture and  the  serious  functional  troubles  which  ordinarily 
accompany  suppurative  interlobar  pleurisy.  This  fissure 
form  of  tuberculosis  is  most  often  discovered  on  radioscopic 
examination  only. 

Examination  of  the  thoracic  cavity  and  heart. — The  form 
and  dimensions  of  the  thoracic  cavity  are  usually  modified 
in  the  tuberculous  on  the  side  affected.  This  modification 
may  be  early  and  attract  attention  in  patients  whose  lesions 
are  still  not  very  extensive  and  give  no  sure  signs.  These 
deformations  are  found  both  in  patients  with  latent  and 
inactive  lesions  and  in  patients  who  have  had  previously 
a  benign  pleurisy  which  has  gone  on  undetected. 

Radioscopically  they  appear  as  a  narrowing  of  the  pul- 
monary field;  on  the  diseased  side  the  hemithorax  is  nar- 
rower than  on  the  normal  side.  At  the  same  time  the  ribs 
slant  considerably  downward  and  outward  and  are  nearer 
one  another,  the  intercostal  spaces  being  narrowed.  This 
appearance  is  quite  characteristic,  but  when  it  is  found, 
there  already  exist  as  a  rule  definite  lesions.  Only  excep- 
tionally can  it  be  regarded  as  an  early  sign. 

The  examination  of  the  cardio-vascular  system  is  more 
important.  The  tuberculous  have  usually  a  small,  median 
heart,  projecting  a  very  little  to  the  right  or  the  left  of  the 
median  shadow,  Destot  some  time  ago  drew  attention  to 
the  value  of  this  sign.  It  is  certain  that  it  is  rare  to  find  a 
large  heart  in  the  tuberculous  and  this  fact  ought  to  be  taken 
into  account.  The  small,  median  hearts  show,  if  not  tuber- 
culosis, at  least  a  predisposition  to  it.  On  the  contrary, 
the  existence  of  a  large  heart  in  an  individual  suspected 
of  tuberculosis  ought  to  be  interpreted  in  a  favorable  manner. 
If  a  certain  negative  argument  cannot  be  made  against 
the  existence  of  tuberculosis,  it  will  be  concluded  that  at 
least  the  patient  has  a  greater  resistance  and  gives  a  less 
favorable  field  to  the  development  of  the  disease. 

Study  of  respiration. — It  is  quite  otherwise  with  the  study 
of  respiration,  which  often  has  very  great  interest  from  the 


126  RADIO-DIAGNOSIS:  LUNGS 

point  of  view  of  early  diagnosis.  Normally  the  dome  of 
the  diaphragm  is  clearly  seen  on  the  screen  to  rise  and  fall 
regularly  through  a  somewhat  extensive  excursion  and 
alike  on  both  sides.  In  incipient  tuberculosis  careful  ex- 
amination and  exact  measurements  often  show  early  modi- 
fication of  respiration  of  the  side  affected.  During  expira- 
tion the  two  diaphragm  domes  rise  to  the  same  level,  but 
in  mspiration  their  excursion  becomes  unequal.  The  lower- 
ing of  the  diaphragm  is  less  on  the  diseased  side  and  the 
difference  of  the  level  between  the  two  sides  of  the  diaphragm 
is  at  times  important. 

Authors  have  explamed  this  phenomenon  differently. 
Some  believe  in  the  pleural  theory,  others  in  the  pulmonary 
theory.  The  advocates  of  the  first  admit  that,  the  early 
lesions  being  often  superficial  and  sub-pleural,  there  is 
instantly  produced  a  somewhat  active  reaction  on  the 
serous  surface,  which,  by  a  form  of  secondary  paresis,  helps 
to  reduce  the  movements  of  the  diaphragm.  Those  who 
hold  the  second  theory  are  of  the  opinion  that  the  restricted 
initial  lesions,  even  when  questionable  disseminated  tuber- 
cles are  present,  and  all  the  more  when  they  are  numerous 
and  confluent,  are  sufficient  to  reduce  in  a  marked  degree 
the  pulmonary  elasticity.  As  a  result  of  this  the  respiratory 
capacity  of  the  lung  affected  is  perceptibly  decreased  so 
that  the  air  enters  it  in  a  much  smaller  quantity,  and  con- 
sequently the  excursion  of  the  diaphragm  is  diminished. 

This  sign,  when  it  is  present,  is  of  great  value  from  the 
point  of  view  of  early  diagnosis,  especially  if  it  coincides 
with  a  diminution  of  the  clearness  of  the  apex  and  a  modifi- 
cation of  the  shadow  of  the  hilus  on  the  same  side,  but  it 
must  be  borne  in  mind  that  this  is  often  lacking  even  when 
unquestionable  pulmonary  lesions  already  exist.  In  fact, 
and  in  spite  of  everything,  early  diagnosis  of  incipient  pul- 
monary tuberculosis  remains  one  of  the  most  difficult  clinical 
problems.  Radiological  examination  does  not  eliminate 
this  difficulty,  but  it  should  never  be  neglected  because  it  is 
especially  in  the  difficult  cases  that  the  most  information 


Radiograph  32.     RIGHT  PULMONARY  TUBERCULOSIS  STARTING 
FROM  THE  FISSURE  (IN  A  CHILD) 

A  broad,  dark  band  occupies  the  entire  middle  part  of  the  right  lung  leaving  a 
clear  zone'at  the  apex  and  another  at  the  bass.  The  edges  of  this  band  are  blurred 
and  indistinct  on  both  sides.  Pulmonary  tuberculosis  has  extended  almost  equally 
into  the  two  adjacent  lobes  on  each  side  of  the  fissure. 


Radiograph  33.     PULMONARY   TUBERCULOSIS   BEGINNING   IN    THE 
LOWER  PORTION  OF  THE  UPPER  LOBE  OF  THE  LEFT  LUNG  AND 
THE  INTERLOBAR  FISSURE 
No.  17.     O.  H.     Male.     Age  24.     Clinical  examination:  Pulmonary  tuberculosis, 
chronic,  active,  all  right  lobes.    Pleurisy  on  left.    Question  of  fluid. 
':^  X-ray  examination :  Fibrosis  of  right  lung,  marked  at  right  apex.     Thickening  of 
interlobar  pleura  and  diaphragmatic  pleura.    Emphysema  of  left  lung. 
Diagnosis:  Tuberculosis  right  lung. 


PULMONARY  TUBERCULOSIS  127 

should  be  obtained.  It  cannot  be  concluded  from  a  nega- 
tive examiDation  that  the  lung  is  perfectly  sound.  Positive 
facts  alone  in  medicine  have  an  absolute  value.  Radio- 
scopic  examination  by  disclosing  slight  modifications  of 
clearness,  by  localizing  these  modifications  where  clinical 
examination  has  suspected  them,  will  give  the  clinician 
either  certainty  or  much  greater  assurance. 

Two  other  forms  of  tuberculosis  may  be  included  in  this 
second  group:  miliary  and  infant  tuberculosis,  because 
they  both  give  almost  no  stethoscopic  signs  and  clinical 
diagnosis  is  often  difficult. 

The  miliary  form  is  at  times  only  an  ultimate  step  in  the 
confirmed  tuberculous  patient.  It  passes  unnoticed,  masked 
under  the  more  or  less  pronounced  symptoms  of  the  disease. 
When  it  is  primary,  clinically  it  sometimes  resembles  gastric 
disturbance  or  typhoid  fever.  The  thoracic  symptoms  are 
often  lacking  or  appear  only  at  a  later  stage. 

During  the  last  few  years  several  radiologists  are  said 
to  have  succeeded  in  establishing  the  diagnosis  of  the  miliary 
form  by  means  of  instantaneous  radiographs  showing  the 
existence  of  pulmonary  granulations.  This  has  not  been 
verified  by  Barjon. 

Tuberculosis  of  infants  has  been  the  subject  of  a  very 
interesting  work  by  Ribadeau-Dumas,  Albert  Weil  and 
Maingot  (Societe  de  Pediatrie,  1912).  These  authors,  by 
the  aid  of  instantaneous  radiographs,  have  confirmed  the 
theory  of  Rist  and  Ribadeau-Dumas  showing  that  tuber- 
culosis of  infants  ordinarily  begins  as  a  small  focus  in  the 
lower  lobe,  then  attacks  the  glands  of  the  hilus,  then  the 
tracheo-bronchial  glands,  and  affects  the  apices  only  sub- 
sequent to  these  gland  lesions. 

Pulmonary  Tuberculosis  t\t[th  Definite  Clinical 
AND  Stethoscopic  Signs. — In  this  class  must  be  included 
all  the  many  forms  of  chronic  or  sub-acute  pulmonary 
tuberculosis.  In  all  these  cases  clinical  diagnosis  has  been 
made.  The  greater  number  of  these  patients  show  evident 
clinical  and  stethoscopic  signs:  general  state  of  health  poor. 


128  RADIO-DIAGNOSIS:  LUNGS 

loss  of  weight,  fever,  sweating;  cough,  shortness  of  breath, 
hemoptysis,  purulent  expectoration;  moist  gurgling  rales, 
bronchial  breathing,  cavitj'  signs.  Radiological  examination 
is  used  simply  to  confirm  diagnosis.  Cases  of  pseudo- 
tuberculosis often  occur  among  these  patients  and  it  is 
important  to  distinguish  it  from  true  tuberculosis  because 
it  is  curable.  Radiological  examination  will  at  times  be  of 
great  help  in  dififerentiating  them  when  it  cannot  always 
be  done  in  the  clinic  alone.  In  true  tuberculosis  the  topog- 
raph}' and  extent  of  the  lesions  can  be  better  determined 
by  it  than  by  clinical  examination  and  prognosis  estab- 
lished. Finally,  it  will  help  in  studying  the  development, 
in  disclosing  the  complications  often  unnoticed  but  frequent 
in  tuberculosis,  and  even  in  furnishing  therapeutic  indica- 
tions. 

Radioscopic  appearance  of  the  thorax  in  a  confirmed  tuher^ 
culous  patient. — Nothing  is  more  variable  than  the  radio- 
scopic appearance  of  the  thorax  in  confirmed  tuberculous 
patients.  Everything  may  be  seen  from  the  most  question- 
able shadows  to  the  most  absolute  opacity,  from  the  most 
limited  obscurity  to  total  involvement  of  the  entire  hemi- 
thorax  or  of  both  pulmonary  fields.  The  most  unexpected 
localizations  and  forms  may  be  established.  Briefly,  it  is 
impossible  to  give  an  exact  and  precise  description,  yet 
it  is  possible  to  point  out  a  certain  number  of  general  char- 
acteristics which  are  constantly  seen  by  radioscope  and 
which  may  serve  as  a  guide  in  the  study  of  tuberculosis. 

The  abnormal  shadows  which  are  seen  affect  most  often 
the  region  of  the  apex  and  hilus.  When  they  are  more  ex- 
tensive, these  regions  are  usually  more  opaque.  In  general, 
the  shadows  are  scattered,  varying  in  density,  and  separated 
from  one  another  by  clearer  spaces.  The  term  "mottling" 
(pommelures)  which  is  commonly  used  is  that  which  best 
describes  this  appearance.  Tuberculosis  develops  through 
foci.  In  confirmed  cases  of  tuberculosis  abnormal  shadows 
are  almost  always  found  on  both  sides  but  generally  pre- 
dominating on  the  side  first  affected.     In  advanced  cases 


PULMONARY  TUBERCULOSIS  129 

the  abnormal  shadows  gradually  reach  the  lower  portions 
of  the  lungs  while  the  apices  are  spotted  secondarily  with 
clear  rounded  zones  more  or  less  regular  in  appearance, 
corresponding  to  cavities  made  in  the  disintegrated  paren- 
chyma. 

The  many  complications  which  arise  in  the  course  of  the 
development  of  these  tuberculous  cases  usually  give  rise 
to  modifications  of  these  data.  Congestive  attacks,  centers 
of  pneumonia  or  broncho-pneumonia,  pleurisy  of  the  large 
cavity,  or  encysted  pleurisy  give  rise  continually  •  to  new 
pictures  whose  interpretation  is  useful  and  interesting. 

Pseudo-tuberculosis. — Clinically  there  are  a  good  many 
non-tuberculous  patients  who  may  at  any  time  give  symp- 
toms of  confirmed  tuberculosis.  They  are  generally  chronic 
patients  who  have  been  coughing  and  expectorating  for 
months  and  at  times  even  years.  They  have  lost  weight, 
appetite  and  strength,  are  even  cachectic,  have  profuse 
sweating  and  fever.  Their  cough  is  accompanied  by  short- 
ness of  breath,  purulent  expectoration,  sometimes  hemop- 
tysis. Auscultation  of  the  thorax  shows  evident  and  even 
extensive  stethoscopic  signs,  labored  respiration,  moist 
gurgling  rales,  cavity  signs.  Sometimes  the  general  health 
remains  good  but  the  auscultatory  signs  are  so  marked  and 
persistent  that  they  suggest  a  center  of  pulmonary  tuber- 
culosis. These  patients  are  affected  at  times  with  purulent, 
encysted  pleurisy,  interlobar  or  otherwise,  sometimes  with 
abscess  of  the  lung,  cancer  of  the  lung,  hydatid  cyst  of  the 
thorax,  pulmonary  syphilis,  dilatation  of  the  bronchi, 
actinomycosis  of  the  lung,  etc. 

Fairly  often  clinical  examination  alone,  the  study  of  the 
development,  an  examination  of  the  sputum  and,  if  need 
be,  inoculation,  will  suffice  to  detect  these  pseudo-tuberculous 
cases,  but  very  often  this  is  insufficient  and  it  is  of  great 
importance  that  it  be  determined  earlier  because  immediate 
intervention  may  save  these  patients. 

Beclere  has  reported  a  case  of  a  child  of  five  years  of  age 
who  for  a  long  time  was  throught  to  be  tuberculous,  in  whom 


130  RADIO-DIAGNOSIS:  LUNGS 

radioscopic  examination  disclosed  finally  the  presence  of  a 
suppurative  interlobar  pleurisy.  The  child  succumbed  in 
spite  of  intervention  because  it  was  too  late. 

In  the  chapter  on  interlobar  pleurisy  Bar j on  has  pointed 
out  a  patient  who  entered  his  service  as  tuberculous,  who 
for  seventeen  years  had  an  empyema  which  was  incom- 
pletely emptied  by  vomica.  The  patient  remained  a 
chronic  cougher,  had  purulent  expectoration  and  hemoptysis 
but  was  cured  by  surgical  intervention. 

Radioscopic  examination  is  therefore  important,  as  this 
patient  showed  the  lung  to  be  sound  and  a  definite  pleural 
collection  to  be  localized  at  the  level  of  the  interlobe.  The 
idea  of  tuberculosis  was  in  this  way  definitely  discarded. 

Bar  j  on  examined  at  home  with  a  portable  machine  a 
patient  who  had  a  cough  and  fever  for  many  months  and  was 
reduced  to  a  state  of  great  emaciation.  He  was  considered 
an  advanced  and  incurable  case  of  tuberculosis.  A  relative 
of  the  patient  insisted  on  a  radioscopic  examination.  Bar  j  on 
found  at  the  base  of  the  lung  a  defined  oval  shadow,  with 
contours  well  limited,  while  the  rest  of  the  lung  was  perfectly 
clear  with  nothing  abnormal  at  the  apex.  Lung  abscess  was 
thought  of  and  surgical  intervention  advised.  The  surgeon 
two  days  later  found  a  purulent  intrapulmonary  collection, 
emptied  and  drained  it,  and  the  patient  had  a  perfect  re- 
covery. 

Early  cancer  of  the  lung  is  at  times  difficult  to  diagnose. 
The  patients  become  thin  and  cachectic,  cough  and  have 
frequent  hemoptysis.  Examination  of  the  thorax  shows 
stethoscopic  signs  locaHzed  at  the  apex,  for  early  cancer  of 
the  lung  usually  affects  the  upper  lobe.  This  disease  also 
often  assumes  the  appearance  of  tuberculosis.  The  radio- 
scope  is  one  of  the  means  at  the  clinician's  disposal  to  correct 
his  diagnosis.  Examination  on  the  screen  shows  the  abnor- 
mal shadow  more  homogeneous,  more  limited,  less  diffuse 
than  that  of  tuberculosis.  In  the  tuberculous  with  a  shadow 
at  the  apex  there  follows  a  series  of  uneven  mottlings  which 
infiltrate  in  a  diffuse  manner  the  pulmonary  parenchyma 


Radiograph  34.  CHRONIC  SIMPLE  BILATERAL  TUBERCULOSIS- 
DISINTEGRATION  AND  CAVITY  LESIONS 
The  two  pulmonary  fields  are  studded  with  diffuse  shadows — a  mottled  appear- 
ance. A  somewhat  clear  zone  at  the  right  apex — the  supra  and  sub-clavicular 
region  (cavity).  Autopsy. — Diffuse  pulmonary  tuberculosis  of  the  suppurative 
broncho-pneumonic  form.  The  right  lung  shows  a  large  cavity  which  occupies  the 
entire  upper  lobe.  Disintegrating  and  cavities  in  the  middle  lobe;  infiltration  of 
the  lower  lobe.  Diffuse  sclerosis.  The  left  lung  shows  disintegration  and  many 
small  cavities  in  the  upper  lobe;  infiltration  of  the  lower  lobe. 


Radiograph  35.  PULMONARY  MYCOSIS  SIMULATING  TUBERCULOSIS 
A  somewhat  extensive  obscurity  of  the  right  apex  with  a  clear  zone  (cavity). 
Less  extensive  obscurity  of  the  left  apex.  Clinical  development — fistula  in  the 
thoracic  wall  of  the  pulmonary  cavity.  Metastasis  in  the  calf  of  the  leg.  Labora- 
tory examination  shows  that  it  is  a  mycosis  and  not  tuberculosis. 


PULMONARY  TUBERCULOSIS  131 

without  any  definite  lower  outline.  The  opposite  apex  al- 
most always  shows  some  anomaly.  In  early  cancer  the 
shadow  is  more  clearly  defined  by  the  interlobe;  the  line  of 
demarcation  is  clear;  below,  the  lung  remains  clear,  the 
opposite  apex  is  normal. 

Such  are  the  radioscopic  findings  that  are  to  be  relied  upon. 
Bar j  on  found  them  in  precise  form  in  two  cases,  but  perhaps 
they  will  not  always  be  as  clear. 

Another  patient  with  the  diagnosis  of  pleurisy  and  con- 
gestive attacks  of  the  apex  with  hemoptysis  showed  on  radio- 
scopic examination  the  existence  of  an  hydatid  cyst  of  the 
thorax  with  its  characteristic  picture,  regularly  spherical 
with  contours  well  demarcated.  The  apex  showed  no  other 
abnormal  shadow.  It  was  only  a  little  lighter,  compression 
diminishing  its  elasticity  and  respiratory  capacity.  Surgical 
intervention  confirmed  the  diagnosis  and  cured  the  patient. 

Patients  affected  with  dilatation  of  the  bronchi  often  pass 
as  tuberculous.  Clinical  diagnosis  is  ordinarily  made  because 
of  the  slowness  of  development,  preservation  of  general  good 
health,  localization  of  the  stethoscopic  signs  towards  the 
bases,  the  absence  of  Koch's  bacilli  in  the  sputum.  Tuber- 
culosis when  occurring  at  the  bases  should  always  be  treated 
with  suspicion.  Radioscopic  examination  may  be  useful. 
In  dilatation  of  the  bronchi  there  are  present  only  very 
questionable  abnormal  shadows,  a  little  diffuse  obscureness 
towards  the  bases  but  no  characteristic  picture.  There  is  a 
contrast  between  the  abundance  and  the  intensity  of  the 
auscultatory  signs  and  the  slight  opacity  of  the  region. 
True  tuberculous  lesions  give  denser  shadows;  and  when  a 
contrast  does  exist,  the  auscultatory  signs  are  rather  reversed, 
that  is  to  say,  there  appears  on  the  screen  an  area  relatively 
much  darker,  in  which  auscultation  gives  much  fewer  signs. 

Pulmonary  syphilis  in  some  cases  may  also  simulate  tuber- 
culosis. Beclere  in  1911  and  Bensaude  and  Emery  in  1913 
(d  la  Societe  medicale  des  hopitaux)  demonstrated  the  part 
of  radiological  examination  in  these  cases.  It  establishes, 
on  the  one  hand,  the  presence  of  abnormal  shadows  and,  on 


132  RADIO-DL\GNOSIS:  LUNGS 

the  other  hand,  follows  theu*  progressive  and  rapid  disappear- 
ance under  specific  treatment.  Barjon  followed  on  the  screen 
a  patient  of  Dr.  Paul  Courmont  affected  with  pulmonary 
mycosis.  Radioscopic  examination  showed  a  diffuse  shadow 
at  the  apex  somewhat  like  that  of  simple  tuberculosis.  At 
the  end  of  some  time  a  ca\'ity  was  formed  in  this  apex.  Its 
presence  was  evident  both  stethoscopically  and  radioscopic- 
ally.  Everything  pointed  to  tuberculosis,  but  the  examina- 
tion of  the  sputum  for  Koch  bacilli  was  constantly  negative 
and  doubt  persisted.  Diagnosis  was  made  later  by  the  ap- 
pearance of  a  metastasis  in  the  calf  of  the  leg;  in  the  pus  char- 
acteristic yellow  granules  were  found  and  microscopic  exam- 
ination showed  the  specific  parasite. 

As  a  result  of  the  cavity  at  the  apex,  a  fistula  formed  under 
the  skin  in  the  supra-spinous  fossa,  confirming  the  diagnosis 
of  mycosis  of  the  lung.  In  this  case  the  radioscopic  examina- 
tion furnished  no  information  which  could  indicate  the  true 
diagnosis. 

In  spite  of  this  exception,  pseudo-tuberculous  or  abnormal 
tuberculous  cases  ought  to  be  submitted  to  radiological  in- 
vestigation. In  the  great  majority  of  cases  valuable  indica- 
tions will  result  from  this  examination  which  will  correct 
diagnosis  and  ascribe  to  their  true  cause  chronic  pulmonary 
affections  which  assume  in  their  progress,  symptoms,  and 
development,  the  appearance  of  tuberculosis. 

Topographic  study  of  the  lesions  in  tuberculous  cases. — In 
confirmed  tuberculosis,  radioscopic  examination  has  no 
part  in  establishing  diagnosis,  but  it  is  very  useful  in  de- 
termining the  topography  and  extent  of  the  lesions.  Nothing 
is  so  deceptive  as  stethoscopic  examination  from  this  point 
of  view.  Often  deep,  extensive  lesions  covered  over  by  a 
portion  of  sound  lung  have  given  no  evidence  on  ausculta- 
tion. As  a  general  rule,  after  a  tuberculous  patient  has 
been  carefully  examined  and  the  topography  and  the  extent 
of  his  lesions  have  been  carefully  determined,  the  radio- 
scopic screen  will,  in  the  majority  of  cases,  reveal  lesions 
more  extensive  than  suspected.    Inversely,  when  a  tuber- 


PULMONARY  TUBERCULOSIS  133 

culous  patient  enters  the  hospital  at  the  heif^ht  of  exhaus- 
tion, with  fever,  violent  attacks  of  coughing,  abundant 
purulent  expectoration,  auscultation  gives  coarse  moist 
rales  over  a  large  area,  sometimes  generalized,  and  the 
impression  is  that  there  is  an  extensive  softening  of  both 
lungs.  In  this  case  radioscopic  examination  shows,  on  the 
contrary,  an  opaque  area,  sometimes  rather  limited,  while 
the  rest  of  the  lung  has  retained  its  transparency  in  spite 
of  the  many  coarse  moist  rales  found  there. 

The  immediate  prognosis  in  this  case  is  very  different, 
for  it  is  a  primary  tuberculous  focus  which  may  be  of  long 
standing  and  which,  under  fatigue,  has  become  the  starting 
point  for  a  diffuse  bronchial  attack,  intense,  with  abundant 
secretion,  bronchial  involvement,  moist  rales,  purulent 
expectoration,  fever,  sweatings,  etc.  Some  days  rest  in 
bed  is  enough  to  confirm  the  radioscopic  examination.  The 
inflammatory  attack  subsides,  the  bronchi  empty  them- 
selves, rales  disappear,  fever  falls,  and  there  are  no  longer 
any  stethoscopic  signs  except  in  a  limited  portion  corre- 
sponding exactly  to  the  old  primary  lesion  which  was  demon- 
strated on  the  fluoroscopic  screen. 

It  has  been  shown  that  in  early  tuberculosis,  radiological 
examination  is  never  infallible.  Sometimes  auscultation 
is  first  in  importance,  sometimes  the  radioscope.  There 
may  be  a  clearly  visible  shadow  when  nothing  is  heard,  or 
evident  auscultatory  signs  may  exist  when  the  screen  shows 
nothing  abnormal.  There  is  therefore  no  accurate  rule 
from  the  point  of  view  of  early  diagnosis.  (See  Radiographs 
29  and  30.) 

It  is  quite  otherwise  from  the  point  of  view  of  prognosis 
and  the  appreciation  of  the  extent  of  the  lesions  in  con- 
firmed tuberculous  cases.  Here  the  radioscope  is  clearly 
superior  to  auscultation  and  it  is  to  indications  obtained 
by  it  that  the  greatest  importance  should  be  attached. 

In  confirmed  tuberculosis,  if  there  is  a  disagreement 
between  the  findings  obtained  by  auscultation  and  the 
radioscope,  the  greater  importance  should  be  accorded  to 


134  RADIO-DIAGNOSIS:  LUNGS 

the  latter.  If,  for  example,  only  some  scattered  rdles  are 
heard  on  auscultation  while  the  screen  shows  diffuse,  ex- 
tensive obscureness,  the  prognosis  is  bad.  If,  on  the  con- 
trary, pronounced  and  extensive  auscultatory  signs  are 
present  while  the  radioscope  shows  the  pulmonary  field  has 
retained  for  the  most  part  its  transparency,  prognosis  is 
less  grave — at  least  for  the  present. 

Study  of  the  development  of  lesions  in  tuberculosis. — It 
is  ver}'  interesting  to  follow  the  development  of  lesions  in 
the  tuberculous  patient,  to  see  them  contract  and  become 
cicatrized  or,  on  the  contrary,  extend  and  become  caseated 
and  soften.  To  observe  this,  patients  are  regularly  ex- 
amined, and  the  changes  in  physical  and  functional  signs 
which  have  any  bearing  on  the  study  of  the  underlying 
lesions  are  followed  by  palpation,  percussion  and  ausculta- 
tion. 

A  radioscopic  examination  of  a  tuberculous  patient  is 
not  limited  to  a  single  time  to  confirm  diagnosis  and  to 
judge  of  the  extent  of  the  lesions.  It  is,  on  the  contrary,  very 
instructive  to  continue  to  make  radioscopic  examinations 
almost  as  often  as  auscultation  to  compare  the  difference 
from  time  to  time.  A  study  therefore  can  be  made  at  the 
same  time  by  both  methods  of  the  development  of  the 
lesions  in  one  sense  or  another,  and  useful  indications  can 
be  drawn  for  prognosis  and  treatment. 

WTien  a  tuberculous  center  is  healed,  it  is  not  seen  to 
disappear  on  the  radioscopic  screen;  it  persists  even  when 
completely  cicatrized.  The  abnormal  shadow  indicates 
alwaj'^s  the  site  of  the  healed  lesions,  although  auscultation 
has  been  negative  for  a  long  time.  The  process  of  healing 
can  however  be  followed  on  the  screen.  If  the  abnormal 
shadow  does  not  disappear,  it  is  reduced:  the  inflammatory 
zone  which  surrounds  it  and  makes  it  appear  larger  and  more 
diffuse  disappears.  The  contours  become  more  clearly 
demarcated.  At  the  same  time  the  abnormal  shadows 
produced  by  the  inflammatory  process  adjacent  to  the 
bronchial  and  peribronchial  glands  become  lighter,  or  even 


Radiograph  38.  PULMONARY  TUBERCULOSIS  WITH  VERY  SLOW 
PROGRESS  (30  YEARS),  SCLEROTIC  TENDENCY 
Total  obscurity  of  the  right  apex  with  a  clear  zone — cavity.  Very  dense  shadows 
in  the  region  of  the  hilus  on  both  sides.  Small  scattered,  very  opaque  spots.  De- 
velopment— began  at  twenty-two  years  with  bronchitis.  Attack  of  tuberculous 
broncho-pneumonia  at  thirty-three  years.  Slow  progress  with  periods  of  remission. 
Died  at  fifty-three  years  of  age.  Autopsy — right  pleural  adhesions.  Right  lung — 
induration  of  the  apex  with  old  cavity  outlined  by  rigid  calcareous  walls.  CEdema- 
tous  congestion  of  the  base.  Left  lung — sclerosis  and  emphysema.  No  center  of 
caseation.     Some  hard  sclerotic  glands  toward  the  hilus. 


Radiograph  39.     UNILATERAL     TUBERCULOSIS.       CAVITY     OF     THE 

RIGHT  APEX 

In  the  upper  part  of  the  right  lung  three  clear  zones  surrounded  by  dark  outlines 
separating  them  from  one  another  (cavities  of  the  right  apex).  Diffuse  and  ques- 
tionable shadows  in  the  lower  part  of  the  right  lung.    Left  lung  retains  its  clearness. 


PULMONARY  TUBERCULOSIS  135 

disappear.  The  hilus  shadow  becomes  less  extensive  and 
opaque. 

On  the  contrary,  when  tuberculosis  advances,  the  extent 
and  opacity  of  the  shadows  already  existing  gradually  in- 
crease and  new  ones  are  produced.  The  mottling  becomes 
more  marked  and  attacks  the  lower  lobes.  The  pulmonary 
shadows  gradually  unite  with  the  shadow  of  the  enlarged 
hilus,  become  fused  and  more  dense  so  that  eventually  it 
becomes  impossible  to  distinguish  them.  At  the  same  time 
that  the  lesions  extend,  they  progress.  By  degrees  they 
become  softened  and  pulmonary  cavities  form. 

Pulmonary  cavities. — Professor  Bouchard  first  suggested 
that  pulmonary  cavities  could  be  seen  on  the  screen.  Ordi- 
narily they  are  seen  as  clear  areas,  highly  illuminated, 
situated  in  the  middle  of  a  dark  zone.  The  form  of  this  clear 
bubble  is  more  or  less  regularly  round  and  is  limited  by  an 
opaque  ring  which  outlines  its  contour  and  corresponds  to 
the  sclerosis  and  congestion  which  is  taking  place  around  the 
cavity.  This  characteristic  circle  prevents  confusion  with 
the  healthy  tissue  persisting  in  the  center  of  an  infiltrated 
zone.  However,  this  appearance  is  not  always  as  character- 
istic and  often  pulmonary  cavities  discernible  on  auscultation 
remain  invisible  to  Roentgen  rays.  The  conditions  which 
explain  this  invisibility  are  as  follows : 

First,  it  is  a  question  of  size  and  dimensions  and  it  is  cer- 
tain that  small  cavities  may  pass  unnoticed.  In  order  that 
they  may  become  visible  they  must  contain  sufficient  quan- 
tity of  air  to  give  a  clear  picture  on  the  screen ;  that  is  to  say, 
that  they  obtain  at  least  the  dimensions  of  a  walnut.  The 
larger  the  cavities,  the  greater  their  chances  of  being  seen. 
Next,  it  is  a  question  of  location.  The  more  superficial  a 
cavity,  the  more  distinct  it  is.  On  the  contrary,  the  deeper 
it  is,  the  less  visible.  There  are  anterior  cavities  which  are 
seen  only  in  the  frontal  position  and  not  at  all  in  the  dorsal 
position.  Inversely,  certain  posterior  cavities  are  seen  only 
in  the  dorsal  position.  In  contrast,  there  are  cavities  suffi- 
ciently large  and  located  in  such  a  way  that  they  are  as  easily 


136  RADIO-DL\GNOSIS:  LUNGS 

visible  iii  front  as  in  back.  The  structure  of  the  puhiionary 
parenchyma  around  the  cavity  also  has  a  great  influence  on 
its  visibility.  If  the  cavity  is  surrounded  by  tissue  showing 
only  a  low  density,  its  clearness  will  readily  stand  out  on  the 
light  shadow  of  this  tissue.  But  if  the  cavity  is  surrounded 
by  a  dense  tissue,  is  situated  in  front,  or  in  back  of  a  very 
opaque  hepatization  or  caseation,  the  opacity  of  the  paren- 
chyma will  neutralize  the  clearness  of  the  cavity,  which  con- 
sequently will  become  invisible,  for  the  radioscopic  image 
is  only  the  result  of  pictures  furnished  by  the  different  trans- 
verse tissues. 

Barjon  found  by  autopsy  two  small,  central  cavities  of 
the  right  apex  the  thick  walls  of  which  were  infiltrated  with 
calcareous  salts.  They  had  not  been  recognized  either  clin- 
ically or  radioscopically. 

Finally,  the  degree  of  fullness  or  emptiness  of  the  cavity 
exerts  considerable  influence  on  the  radioscopic  appearance. 
A  cavity  filled  with  pus  will  give  a  uniform  opaque  shadow 
and  not  at  all  a  picture  characteristic  of  cavity.  If  it  is 
empty,  the  clear  area  surrounded  by  a  dark  ring  will  reappear. 
Finally,  if  it  is  half  empty,  an  opaque  shadow  below  a  clear 
area  appears,  the  two  zones  being  separated  from  one  an- 
other by  a  narrow  movable  line,  giving  the  appearance  of  a 
partial  pyopneumothorax,  provided  the  cavity  is  of  large 
enough  dimensions. 

In  1912  Barjon  performed  an  autopsy  on  a  tuberculous 
patient  fifty-six  years  old,  in  whom  the  unusual  dimensions  of 
the  cavity  and  the  appearance  of  the  radioscopic  image  had 
made  him  think  it  a  case  of  a  partial  pneumothorax.  Thus 
the  same  cavity  in  the  same  patient  may  give  from  day  to 
day  different  shadows,  appear,  disappear,  and  become  modi- 
fied, according  to  whether  the  cavity  is  filled  with  pus  or 
whether  the  secretions  have  been  totally  or  partially  emptied. 

Study  of  the  complications  in  tuberculosis. — Lorrain  has 
stated  that  pulmonary  tuberculosis  is  only  a  series  of  pneu- 
monias ;  Louis  that  it  is  only  a  succession  of  pleurisies.  There 
is  a  great  deal  of  truth  in  both  these  affirmations.     So  the 


PULMONARY  TUBERCULOSIS 


137 


term  ''complication"  used  at  the  beginning  of  this  chapter 
is  not  absolutely  correct.  In  reality  the  many  and  varied 
pleural  and  pulmonary  processes  that  are  produced  in  the 
course  of  the  development  of  pulmonary  tuberculosis  are  not 
complications  but  the  sequence.  They  are  the  natural  reac- 
tions of  the  lung  and  of  the  pleura  against  the  disease,  from 
which  there  are  a  series  of  attacks  of  congestion,  pneumonia, 
broncho-pneumonia  and  on  the  other  hand,  a  series  of  at- 
tempts at  rest  and  immobilization  by  pleural  adhesions, 
symphyses,  sclerosis,  effusions,  or  partial  pleurisies. 


Fig.  24 
Pneumonia  on  the  left  side  with  pneumonic  triangle,  in  an  advanced  tuberculous 
case  having  lesions  already  pronounced  on  the  right  and  more  questionable  in  the 
left  apex. 

All  these  different  processes,  some  of  which  are  very  diffi- 
cult to  determine  clinically,  give  radioscopic  pictures  which 
may  be  sufficiently  characteristic  to  allow  of  diagnosis. 

Attacks  of  congestion  are  usually  produced  in  the  apical 
areas.  They  are  ordinarily  easy  to  recognize  because  accom- 
panied by  rise  of  temperature  and  often  by  hemoptysis. 
Radioscopically  they  are  seen  as  a  somewhat  opaque  diffuse 
shadow  of  the  apex  involved  and  if  it  is  a  question  of  tuber- 
culosis which  has  akeady  been  observed  on  the  screen,  a 
perceptible  difference  can  be  noticed.    The  opacity  is  con- 


138  RADIO-DIAGNOSIS:  LUNGS 

siderably  more  than  on  first  examination.  Sometimes  the 
radioscope  serves  only  as  a  control.  It  is  quite  different  in 
pneiin;onia,  which,  when  it  occurs  in  a  fully  developed  ease 
of  tuberculosis,  may  easily  pass  unpercived . 

It  does  not  show  the  characteristics  of  the  sudden  onset 
of  frank  pneumonia  which  occurs  in  full  health.  On  the 
contrary,  it  is  seen  in  a  febrile  patient.  There  is  lacking  the 
onset  with  chill,  the  stitch  in  the  side  and  characteristic  ex- 
pectoration. Radioscopic  examination  therefore  may  at 
tunes  be  useful  in  demonstrating  the  presence  of  a  pneumonic 
process.  In  certain  cases  the  axillary  triangle  described  by 
Weill  and  ]\Iouriquand  in  children  may  be  very  clearly  seen. 
Barjon  saw  it  in  a  young  woman  of  about  thirty  years  of  age 
in  whom  the  tuberculous  lesions  were  but  slightly  advanced. 
The  apical  lesions  appeared  on  the  screen  as  scattered  grayish 
spots  and,  on  the  other  hand,  the  pneumonic  area  as  a  very 
opaque  axillary  triangle.  Barjon  also  saw  it  in  a  man  twenty- 
eight  years  of  age  who  showed  advanced  tuberculous  lesions 
of  the  right  side  and  questionable  lesions  of  the  left  apex  and 
who  had  on  the  left  side  a  pronounced  pneumonic  process. 

However,  in  adults  pneumonia  does  not  always  give  the 
triangular  figure,  but  may  be  seen  as  an  opaque,  rather 
extensive  shadow,  covering  an  entire  pulmonary  lobe.  If 
this  occurs  in  a  well  advanced  tuberculous  case  which  al- 
ready shows  an  obscurity  quite  marked  and  somewhat 
extensive  in  the  apex,  the  radioscopic  picture  is  very  likely 
to  attract  no  special  attention. 

Broncho-pneumonia  in  tuberculous  cases  does  not  give 
a  characteristic  picture.  It  is  seen  as  a  series  of  dark  spots, 
more  or  less  distinct,  or  more  or  less  confluent,  sometimes 
analogous  to  the  mottling  already  described,  sometimes 
showing  a  more  or  less  extensive  diffuse  obscurity. 

Radioscopic  examination  is  more  useful  in  determining 
pleural  processes,  w^hich  in  the  tuberculous  often  remain 
unnoticed. 

Pleurisies  of  the  large  cavity,  which  have  already  been 
treated,  will  not  be  considered  again.     Apart  from  large 


PULMONARY  TUBERCULOSIS  139 

initial  pleurisies,  pleurisy  with  slight  effusion  is  met  with 
in  the  tuberculous  and  may  occur  in  all  stages  of  the  disease. 
These  pleurisies  are  constantly  insidious  and  unnoticed. 
Radioscopically,  they  do  not  always  show  the  character- 
istic pictures  because  they  occur  in  a  pleura  often  abnormal 
on  account  of  adhesions.  Ordinarily  the  quantity  of  fluid 
is  insufficient  to  produce  a  displacement  of  the  heart  and  of 
the  mediastinum. 

The  obscurities  of  the  base  which  completely  efface  the 
contour  of  the  diaphragm  and  the  costodiaphragmatic 
sinus  should  always  be  suspected  in  tuberculosis.  Nine 
times  out  of  ten  pleural  processes  are  present,  either  simple 
exudates  with  adhesions,  or  effusions  more  or  less  encysted 
or  limited.  This  has  been  verified  many  times  by  autopsy. 
These  localizations  can  be  made  either  on  the  side  of  the 
pulmonary  tuberculous  lesion,  which  is  most  frequent,  or 
on  the  opposite  side.  An  exploratory  puncture  will  at  times 
be  useful.  Encysted  pleurisies,  especially  diaphragmatic  and 
interlobar,  are  somewhat  frequent  in  tuberculosis  and  diffi- 
cult to  recognize  by  clinical  and  stethoscopic  examination. 

The  radioscopic  study  of  encysted  pleurisies  has  already 
been  considered,  as  well  as  that  of  interlobar  sclerosis  and 
total  and  partial  adhesions. 

Of  all  the  complications  which  may  arise  in  the  tuber- 
culous, penumothorax  is  surely  the  one  for  the  diagnosis 
of  which  the  radioscopic  examination  is  most  useful. 

In  typical  clinical  pneumothorax  with  sudden  onset, 
violent  stitch  in  the  side,  intense  dypsnoea,  etc.,  penetration 
of  air  into  the  pleural  cavity  can  be  verified  and  the  position 
of  the  lung  determined,  as  well  as  its  degree  of  retraction 
and  compression  and  the  adhesions  which  hold  and  deform 
it.  The  development  of  this  complication  can  be  followed 
and  its  transformation  into  pyopneumothorax  by  infection 
of  the  pleura  and  the  formation  of  an  effusion.  This  ex- 
amination, made  without  any  definite  object  in  ordinary 
tuberculosis,  has  shown  the  presence  of  an  old  pyopneumo- 
thorax until  then  disregarded. 


140  RADIO-DIAGNOSIS:  LUNGS 

Radioscopic  examination  and  treatment  of  tuberculosis. — 
The  results  of  radioscopic  examination  may  be  useful  in 
the  treatment  of  tuberculosis  after  having  furnished  in- 
dications, for  diagnosis  and  prognosis.  By  enabling  us  to 
follow  the  development  of  the  lesions,  their  extensive  or 
regressive  tendency,  by  revealing  very  early  the  existence 
of  deep  areas  inaccessible  to  stethoscopic  examination,  the 
radioscope  helps  to  determine  the  indications  for  a  rational 
and  medical  cure  of  pulmonary  tuberculosis. 

But  it  is  still  more  useful  in  establishing  the  indications 
and  contra-indications  for  surgical  treatment.  This  treat- 
ment, which  consists  of  the  application  of  Forlinini's  method 
or  artificial  pneumothorax,  has  been  much  employed  in 
the  course  of  the  last  few  years. 

Aside  from  its  great  success,  there  have  been  some  grave 
accidents  and  also  some  regrettable  errors.  The  treatment 
is  far  from  being  inoffensive  and  the  indications  and  contra- 
indications should  be  determined  with  the  greatest  of  care. 

Among  the  most  important  conditions  we  must  take  into 
account  the  following:  tuberculosis  must  be  unilateral,  or 
at  least  the  other  lung  ought  to  show  no  lesion  of  a  pro- 
gressive nature. 

On  the  other  hand,  the  lung  to  which  the  treatment  is  to 
be  applied  ought  to  be  as  free  as  possible  of  adhesions  so 
that  it  may  be  compressed  regularly  and  in  an  equal  manner 
on  all  sides.  Some  adhesions  may,  as  the  case  requires,  be 
broken  up.  A  total  or  even  a  partial  adhesion  prevents  the 
separation  of  the  pleura,  exposes  it  to  danger  or  interferes 
with  the  result. 

Radioscopic  examination  may  furnish  on  this  subject 
the  most  interesting  information,  and  it  would  actually  be 
dangerous  and  even  culpable  to  practise  an  artificial  pneu- 
mothorax on  a  tuberculous  patient  without  having  previously 
submitted  him  to  a  minute  radiological  examination. 

Cured  tuberculous  patients. — Cured  tuberculosis  often 
leaves  in  the  lungs  more  traces  perceptible  to  radioscopic 
examination  than  to  auscultation.     Most  often  very  dis- 


PULMONARY  TUBERCULOSIS  141 

tinct  and  at  times  extensive  abnormal  shadows  are  found. 
They  are  generally  localized  at  the  level  of  the  hilus  and 
apices  but  may  be  found  in  any  other  part  of  the  lungs. 
Often  they  are  made  up  of  opaque  shadows  with  clear  con- 
tours, well  defined,  but  of  small  extent,  corresponding  to 
the  cicatricial  areas  having  undergone  fibrous  or  calcareous 
degeneration. 

What  makes  them  more  apparent  is  the  frequent  exist- 
ence of  a  contiguous  zone  of  compensatory  emphysema, 
the  exaggerated  clearness  of  which  contrasts  with  the  sur- 
rounding shadow.  At  other  times  there  is  diffuse  obscurity 
of  the  whole  of  one  apex,  corresponding  to  a  zone  of  some- 
what extensive  sclerosis.  There  is  added  to  this  at  times  a 
little  thickening  of  the  interlobes,  a  lack  of  development 
of  the  costodiaphragmatic  sinus,  and  a  diminution  in  ampli- 
tude of  the  respiratory  movement. 

It  is  not  uncommon  to  note  also  retraction  of  the  thorax 
and  ribs,  and  displacement  of  the  mediastinum,  aorta  and 
trachea. 


CHAPTER  V 
LUNG  TUMORS 

CANCER  OF  THE  LUNG.— Cancer  of  the  lung,  ap- 
pearing under  variable  anatomical  forms  (carcinoma, 
sarcoma,  etc.)  may  appear  clinically  under  very  different 
aspects.  Its  diagnosis  is  always  difficult.  Radioscopic 
examination  may  in  certain  cases  be  of  undisputed  useful- 
ness provided  it  is  closely  co-ordinated  with  the  clinical 
findings. 

In  some  cases  only  ordinary  diffuse  shadows  are  found, 
showing  in  themselves  nothing  characteristic.  Often  these 
shadows  extend  to  one  entire  side  of  the  hemithorax  and 
are  less  opaque  and  less  homogeneous  than  those  produced 
by  effusion.  The  opacity  is  sometimes  less  at  the  base  than 
at  the  apex — the  inverse  of  pleurisy — and  there  is  no  dis- 
placement of  the  heart  nor  of  the  mediastinum.  This  image 
arouses  suspicion  by  its  abnormal  appearance.  Nor  does 
it  recall  the  classical  forms  of  tuberculosis.  It  is  excep- 
tional for  tuberculosis  to  obscure  completely  from  apex 
to  base  an  entire  lung  without  involving  at  the  same  time 
to  some  extent  the  opposite  side. 

These  radioscopic  anomalies,  added  to  clinical  anomalies 
in  symptoms  and  development,  make  one  reject  the  diag- 
nosis of  tuberculosis  and  by  exclusion,  suspect  cancer. 

But  at  other  times  certain  radioscopic  pictures  will  attract 
the  attention  by  some  peculiarity  of  form  or  of  outline. 
A  careful  study  of  these  pictures  added  to  that  of  clinical 
data  will  at  times  be  decisive. 

Barjon  had  occasion  to  observe  radioscopically  seven 
cases  of  lung  cancer  and  each  time  the  radioscope  gave 
very  interesting  indications.  Thi-ee  times  diagnosis  was 
made  which  clinically  was  not  even  suspected.     Twice  it 

142 


4 


Radiograph  40.     EXTENSIVE    TUBERC;UL08LS    OF    THE    LEFT    LUNG 

WITH  CAVITY 
Total  obscurity  of  the  entire  left  lung  with  a  clear  oval  zone  under  the  clavicle. 
On  the  right  scattered  mottled  areas.     Autopsy — extensive  caseous  pneumonia  of 
entire  left  lung  with  large  cavity  under  the  clavicle.     On  the  right  scattered  areas 
of  tuberculous  broncho-pneumonia. 


Radiograph  41.     PRIMARY  LOBAR  CANCER  OF  THE  RIGHT  LUNG 
Total  obscurity  of  the  whole  upper  part  of  the  right  lung.     The  lower  outline 


of  the  shadow  is  clear  and  rectilinear. 
left  lung. 


The  lower  lobe  is  clear  as  well  as  all  of  the 


LUNG  TUMORS  143 

definitely  determined  the  presence  of  lung  cancer  and  twice 
it  merely  confirmed  diagnosis  already  established  clinically. 
All  these  cases  except  one  were  confirmed  by  autopsy. 

It  seems  necessary  to  preserve  radioscopically  the  clinical 
distinction  of  primary  and  secondary  cancer  as  both  usually 
show  different  radiological  characteristics. 

1.  Primary  cancer. — This  form  may  itself  be  divided  into 
lobar  cancer  and  cancer  of  the  hilus,  according  to  where  it 
begins. 

a.  Lobar  cancer. — From  a  radiological  point  of  view,' pri- 
mary lobar  cancer  of  the  lung  is  characterized  by  a  shadow 
in  general  somewhat  extensive,  occupying  one  entire  lobe 
of  the  lung.  The  preference  for  the  upper  lobe  is  quite  appar- 
ent. The  lower  part  of  this  shadow  is  limited  by  a  narrow 
line  indicating  the  direction  of  the  interlobe.  The  sub- 
jacent lobe  keeps  its  entire  clearness.  There  is,  then,  a  clear 
line  of  demarcation  between  the  part  which  has  remained 
clear  and  the  opaque  portion  of  the  lung.  This  picture  has 
some  resemblance  to  frank  pneumonia  of  the  upper  lobe  in 
adults.  It  differs,  however,  by  a  lesser  opacity  and  homo- 
geneousness.  Diagnosis  of  this  disease  is  seldom  decided 
clinically. 

Tuberculosis  is  more  readily  thought  of  in  a  patient  who 
coughs,  expectorates,  has  hemoptysis,  grows  thin,  and  is 
cachectic.  The  stethoscopic  signs — abnormal  breathing, 
moist  rales,  increased  fremitus,  and  dullness  on  percussion — 
all  point  to  a  like  diagnosis.  Under  these  conditions  radio- 
scopic  examination  is  very  important. 

In  tuberculosis  there  is  not  as  a  rule  a  shadow  with  out- 
lines as  clear.  Obscurity  predominates  in  the  apex  and  then 
extends  later  in  a  diffuse  manner  over  the  same  or  the  lower 
lobes  as  scattered  mottled  areas.  It  is  rare,  when  the  lesions 
are  fairly  extensive,  for  the  opposite  side  to  be  absolutely 
normal,  and  most  often  there  are  found  small,  localized 
shadows  either  in  the  apex  or  in  the  vicinity  of  the  hilus. 
On  the  contrary,  in  the  case  of  cancer,  aside  from  some  small 
glands  of  the  hilus  which  may  become  affected  secondarily, 


144  RADIO-DIAGNOSIS:  LUNGS 

the  pulmonary  clearness  on  the  normal  side  from  apex  to 
base  is  persistently  unafifected. 

b.  Cancer  of  the  hilus. — Primary  cancer  of  the  lung  may 
in  certain  cases  begin  in  the  region  of  the  hilus.  In  the  only 
case  which  Bar j  on  observed  a  congenital  malformation  of 
the  lung  existed.  The  left  lung,  in  place  of  being  divided 
by  a  normal  interlobar  fissure  into  two  lobes,  upper  and 
lower  was  divided  by  a  longitudinal  fissure  into  a  short  and 
limited  hilus  lobe  and  a  large  longitudinal  lobe  occupying 


Fig.  25 
Secondary  cancer  of  the  lung,  nodular  form,  following  cancer  of  the  kidney. 

the  entire  length  of  the  hemithorax.  This  last  was  absolutely 
normal  and  the  cancer  remained  limited  to  the  hilus  lobe. 
This  case,  then,  comes  into  the  category  of  lobar  cancer. 

Often  cancer  of  the  hilus  region  is  secondary  to  tumors  of 
the  surrounding  part — cancer  of  the  mediastinum — and  be- 
longs then  in  the  following  class : 

2.  Secondary  cancer. — This  may  appear  under  two  forms: 
a  nodular  form  which  is  quite  characteristic  from  a  radio- 
logical point  of  view,  and  a  diffuse  form,  the  radiological 
diagnosis  of  which  is  much  more  difficult. 

a.  Nodular  form. — Secondary  nodular  cancer  of  the  lung 
on  radioscopic  examination  has  a  quite  characteristic  ap- 
pearance.   There  is  very  plainly  seen  standing  out  against 


LUNG  TUMORS  145 

the  clearness  of  the  lungs  one  or  more  shadows,  round  in 
form,  with  regular,  well  defined  outline.  These  shadows  are 
not  very  deep,  but  in  spite  of  their  relative  superficiality, 
they  stand  out  very  visibly  against  the  clearness  of  the  lungs. 
They  usually  occur  in  the  region  of  the  hilus,  from  which 
they  are  easily  distinguished  by  their  form  and  their  inde- 
pendence of  the  median  shadow,  but  they  may  be  found  also 
right  in  the  middle  of  the  pulmonary  parenchyma. 

These  neoplastic  nodules  are  sometimes  very  numerous, 
but  not  all  are  visible.  On  the  screen  only  those  are  clearly 
differentiated  which  have  already  acquired  a  certain  size. 
This  seldom  exceeds,  as  a  rule,  3  to  4  cm.  in  diameter. 

This  special  form  of  secondary  lung  cancer  is  almost  im- 
possible to  diagnose  clinically  because  there  are  no  steth- 
oscopic  signs.  These  neoplastic  nodules  are  enclosed  in  the 
pulmonary  parenchyma  like  true  foreign  bodies.  They  are 
easily  enucleated  and  do  not  communicate  either  with  the 
bronchi  or  with  the  pulmonary  alveoli.  They  do  not  give 
any  particular  auscultatory  sign.  Being  situated  somewhat 
deep,  owing  to  their  size  they  do  not  give  any  dullness.  All 
that  can  be  observed  are  signs  of  common,  diffuse  bronchitis, 
or  a  small  diminution  in  respiration  when  one  of  these  nodules 
is  localized  in  the  region  of  the  hilus  and  is  able  to  produce  a 
certain  amount  of  compression  of  the  bronchi.  There  is 
then  nothing  characteristic. 

On  the  contrary,  radioscopic  examination  makes  the  di- 
agnosis instantly  without  hesitation.  Indeed  there  is  no 
other  pulmonary  affection  which  shows  like  pictures.  In- 
farct of  the  lung,  which  may  also  be  multiple,  shows  shadows 
much  more  diffuse,  which  never  have  contours  as  clearly  de- 
fined nor  a  form  so  regularly  round.  Hydatid  cysts  are  more 
opaque,  more  regularly  spherical,  and  more  voluminous. 

This  special  nodular  form  corresponds  to  a  particular  form 
of  epithelial  cancer.  In  the  two  cases  of  Barjon's,  it  was 
primary  cancer  of  the  kidney  of  the  epithelial  type  with 
large,  clear  cells. 

b.  Diffuse  form. — Aside  from  the  foregoing  forms,  from  a 


146  RADIO-DIAGNOSIS:  LUNGS 

radiological  point  of  view  quite  clearly  individualized,  there 
are  others  which  are  much  less  so.  It  is  for  this  reason  the 
term  ''diffuse  form"  is  used  to  designate  them. 

It  is  a  case  of  secondarj^  metastasis  developing  usually 
at  the  base  of  one  of  the  lungs.  A  diffuse  shadow  is  seen 
occupying  the  whole  lower  part  of  the  hemithorax  and  more 
or  less  completely  effacing  the  contour  of  the  diaphragm  and 
the  lateral  cul-de-sac.  There  is  no  clear  upper  outline.  The 
shadow  gradually  becomes  effaced  and  is  somewhat  anal- 


FiG.  26 
Secondary  cancer  of  the  lung  localized  at  the  left  base  with  glands  of  the  hilus, 
following  cancer  of  the  testicle. 

ogous  to  pleural  effusion.  The  aspect  differs  from  it,  how- 
ever, by  the  fact  that  the  respiratory  movements  of  the 
diaphragm  are  retained,  contrary  to  what  happens  in  pleu- 
risy. There  does  not  occur,  either,  displacement  of  the  heart 
or  of  the  mediastinum. 

Clinically,  there  is  dullness  at  the  base,  a  diminution  of 
fremitus,  moist  rales,  with  cavity,  or  even  pseudo-cavity 
signs.  Dilatation  of  the  bronchi  might  be  thought  of,  but 
in  that  case  obscurity  of  the  base  is  barely  noticeable. 

Pulmonary  tuberculosis  during  softening  or  cavity  forma- 
tion may  produce  analogous  stethoscopic  signs.  But  it  is 
exceptional  for  these  signs  to  begin  at  the  base  and  to  re- 


Radiograph  42.     SECONDARY  CANCER  OF  THE  LUNG  IN  NODULAR 

FORM 
In  the  left  lung  there  are  only  diffuse  shadows  without  exact  form  but  on  the 
right  in  the  region  of  the  hilus  there  are  two  round  shadows — one  especially  verj' 
apparent,  of  regular  form,  perfectly  detached  against  the  clearness  of  the  paren- 
chyma. Autopsy — primary  cancer  of  the  kidney  with  secondary  centers  in  the 
liver  and  both  lungs.  A  certain  number  of  pulmonary  centers  are  very  small 
(size  of  a  small  pea)  and"  give  no  shadows.  The  ones  visible  are  of  the  size  of  a 
large  walnut. 


Radiograph  43.  DOUBLE  HYDATID  CYST  OF  THE  RIGHT  LUNG 
There  is  very  clearly  seen  in  the  right  lung  the  picture  of  two  superimposed 
hydatid  cysts  whose  shadows,  with  rounded  outline,  overlap  a  little.  The  upper 
cyst  is  at  the  same  time  posterior.  The  lower  is  anterior.  Very  slight  displacement 
of  the  heart  and  of  the  mediastinum.  Intervention — first,  the  removal  of  the 
upper  cyst  and  six  months  later  the  lower  cyst  (Dr.  Albertin).    Recovery. 


LUNG  TUMORS 


147 


main  localized  there.  In  such  a  case  the  radioscopic  exam- 
ination ought  to  bring  out  other  disseminated  shadows  in 
the  upper  part  of  the  lung  and  even  in  the  other  lung. 

On  the  contrary,  in  the  case  of  diffuse  secondary  cancer  all 
the  rest  of  the  respiratory  organs  remain  perfectly  clear.  Cer- 
tain diffuse  centers  of  common  broncho-pneumonia  of  the 
base  must  be  borne  in  mind.  It  is  impossible  also  in  this 
diagnosis  to  separate  the  clinical  and  radioscopic  examina- 
tion, the  latter  being  able  to  add  information  only  of  sec- 
ondary importance. 


Fig.  27 
Interlobar  cancerous  pleurisy,  following  tumor  of  the  mediastinum. 

In  a  single  case,  Bar j  on  observed  a  very  clear  pulmonary 
shadow  outline  with  somewhat  peculiar  form.  It  was  a 
young  man  operated  on  the  year  before  for  a  malignant 
tumor  of  the  testicle  who  showed  grave  pulmonary  signs  of 
the  left  base.  On  radioscopic  examination  there  was  seen 
at  this  level  an  extensive  shadow,  marked  in  the  upper  part 
by  a  clear  irregular  line,  raised  in  the  middle  by  a  rounded 
projection  which  gave  to  the  picture  the  appearance  of  a 
tumor.  There  were  rather  large  glands  of  the  hilus,  but  the 
rest  of  the  pulmonary  field  remained  clear.  Diagnosis  of 
secondary  cancer  of  the  lung  was  made  and  subsequently 
verified. 


148  RADIO-DIAGNOSIS:  LUNGS 

Cancer  of  the  -pleura. — Cancer  of  the  pleura  offers  little 
of  interest  from  a  radiological  point  of  view.  It  is  seen 
most  often  under  the  form  of  pleurisy  of  the  large  cavity 
with  effusion.  Radioscopically  it  does  not  differ  from  ordi- 
nary pleurisy,  treated  in  another  chapter,  and  it  is  for  the 
clinician  alone  to  prove  its  nature. 

Barjon  cites  as  a  matter  of  curiosity  a  case  of  interlobar 
cancerous  pleurisy  which  he  observed  in  the  course  of  the 
development  of  a  mediastinal  tumor.  Diagnosis  was  made 
because  the  development  of  this  mediastinal  tumor  was 
studied  on  the  screen  for  three  months  and  the  complication 
thus  determined. 

Hydatid  cysts  of  the  lung  and  dermoid  cysts  of  the  thorax. — 
Two  kinds  of  cysts  may  be  found  in  the  thorax — hydatid 
cysts,  which  are  always  frankly  pulmonary  in  origin,  and 
dermoid  cysts,  which  arise  rather  in  the  mediastinum. 
These  varieties  of  tumors  are  somewhat  rare.  Dermoid 
cysts  are  even  more  rare  than  hydatid  cysts.  It  is  im- 
portant, however,  to  recognize  them  because  the  findings 
of  the  radiologist  play  a  very  decisive  part  in  their  diag- 
nosis. 

Their  radiological  characteristics  being  almost  the  same, 
it  will  suffice  to  indicate  the  particular  points  which  may 
serve  in  establishing  differential  diagnosis.  Very  few  articles 
have  been  published,  in  France  at  least,  on  this  subject. 
Tuffier,  in  1897  at  the  Congress  of  Moscow,  in  1901  in  the 
''Revue  de  Chirurgie,"  and  again  in  1910  with  Martin  in 
the  same  review,  collected  quite  a  number  of  very  well 
studied  and  very  interesting  cases.  Ronce  in  1907  collected 
only  14  cases  of  hydatid  cysts  of  the  lung,  10  of  which  were 
without  any  radioscopic  examination.  In  4  cases  this 
examination  was  made  by  Beclere. 

Barjon  saw  a  case  of  double  hydatid  cyst  of  the  lung  and 
a  case  of  dermoid  cyst  of  the  thorax.  They  were  verified 
surgically  and  cured. 

Radiological  diagnosis  of  cyst  of  the  thorax  is  generally 
easy.    These  tumors  show  a  peculiar  shadow  of  very  round 


LUNG  TUMORS  149 

form  as  if  traced  by  a  compass,  the  contours  perfectly  defined 
and  standing  out  with  great  distinctness  against  the  clear- 
ness of  the  pulmonary  fields.  No  other  tumor  shows  such 
a  perfect  spherical  appearance,  yet  in  certain  cases  there 
may  be  some  hesitancy.  To  establish  a  certain  diagnosis 
three  questions  should  be  borne  in  mind: 

1.  Is  it  a  cystic  tumor? 

2.  What  is  its  exact  location? 

3.  What  is  its  nature? 

Differential  diagnosis  of  cyst. — When  the  tumor  is  situated 
right  in  the  middle  of  the  pulmonary  parenchyma  and  cir- 
cumscribed all  around  by  a  clear  zone,  its  regularly  rounded 
form  and  its  size  will  determine  diagnosis.  There  is  scarcely 
anything  except  secondary  nodular  cancer  of  the  lung  which 
could  give  analogous  pictures.  But  the  cancerous  nodules 
are  less  regularly  spherical,  less  opaque  and  voluminous. 
When  the  tumor  approaches  the  median  line  and  its  shadow 
becomes  a  part  of  it,  not  being  outlined  except  outside  of 
the  pulmonary  field,  an  aneurysm  of  the  aorta  or  a  medias- 
tinal tumor  are  suggested. 

In  aneurysm  of  the  aorta  the  outlines  are  equally  clear 
and  sometimes  very  rounded.  The  establishment  of  pulsa- 
tion of  the  wall  might  have  a  certain  value  but  it  is  well 
known  that  this  pulsation  is  often  lacking.  Sometimes  the 
radiograph  may  show  details  of  structure,  such  as  uneven 
thickening  of  the  wall,  corresponding  to  calcareous  plaques. 
But  it  is  especially  a  series  of  oblique  examinations  which 
will  eliminate  all  doubt,  showing  the  close  relation  of  this 
tumor  to  the  aorta. 

Tumors  of  the  mediastinum  have  generally  less  regular 
outlines.  Their  edges  are  often  very  obscure  and  difficult 
to  outline  in  places.  They  rise  up  sometimes  high  above 
the  clavicle  and  finally,  they  are  accompanied  ordinarily 
by  gland  obstructions  visible  also  on  the  screen. 

Certain  cases  of  interlobar  pleurisy  with  much  effusion 
may  give  a  picture  as  round  and  as  voluminous  but  never 
showing  a  regularity  as  perfect  as  that  of  cysts.    The  shadow 


150  RADIO-DIAGNOSIS:  LUNGS 

furnished  by  such  a  collection  cuts  the  hemithorax  in  its 
entire  width,  adheres  to  the  median  shadow  on  one  side 
and  follows  up  to  the  external  wall  on  the  other.  It  is  not 
raised  either  above  or  below  more  than  in  the  center.  When 
the  C3'st  is  fairly  large  and  occupies  the  lower  two- thirds 
of  the  hemithorax  so  that  it  completely  obscures  the  base, 
effacing  the  contour  of  the  diaphragm  and  the  pleural  cul- 
de-sac,  producing  displacement  of  the  heart  and  of  the 
mediastinum,  pleurisy  of  the  large  cavity  might  be  thought 
of  and  the  cyst  misinterpreted. 

That  is  what  occurred  in  the  case  reported  by  Desmarest 
(Presse  m^dicale,  June  1st,  1912).  There  are,  however,  in 
such  a  case  indications  which  ought  to  guide  an  expert 
radiologist.  The  form  of  the  upper  outline  of  the  shadow 
should  especially  attract  attention.  When  it  is  decidedly 
convex  and  shows  an  abnormal  form  or  direction,  not  fol- 
lowing the  well-known  rules  of  pleural  curve  formation 
(see  chapter  on  pleurisy),  the  picture  ought  to  arouse  sus- 
picion and  its  interpretation  ought  to  be  discussed.  This 
same  observation  might  allow  us  to  make  a  diagnosis  in 
the  case  of  the  coexistence  of  cyst  and  pleurisy  on  the  same 
side,  the  picture  becoming  analogous  to  the  preceding.  In 
this  case  there  is  at  times  a  quite  appreciable  difference  in 
the  contour  of  the  shadow  according  to  position.  In  the 
dorsal  or  ventral  decubitus  the  fluid  by  being  carried  towards 
the  apex,  effaces  more  or  less  completely  the  contour  of  the 
cyst,  which  takes  on  its  clear,  convex  form  in  the  upright 
position. 

Certain  tumors  of  the  lung  or  of  the  pleura  (sarcoma) 
may  also  give  extensive  shadows,  limited  in  their  upper 
part  by  a  clear,  convex,  semi-circular  contour,  quite  like  a 
cyst.  Barjon  has  observed  an  example  of  this  quite  re- 
cently. 

Diagnosis  of  cyst  localization. — The  topographical  diagno- 
sis has  a  rather  great  importance  from  the  surgical  point 
of  view.  It  ought  to  be  able  to  show  to  the  surgeon  the 
exact  spot  where  he  should  approach  the  tumor.     It  is 


No. 
cyst. 


Radiograph  4.3B 
100.     Tumor  seen  in  right  lung  of  questionable  origin. 


Resembles  hydatid 


Radiograph  44.  DERMOID  CYST  OF  THE  LEFT  HEMITHORAX 
An  enormous,  opaque  shadow,  regularly  rounded,  occupies  all  the  lower  part  of 
the  left  hemithorax.  Below  a  clear  triangle  persists  at  the  level  of  the  sinus. 
Marked  displacement  of  the  heart  and  mediastinum  to  the  right.  Intervention — 
cyst  opened;  elimination  of  an  enormous  amount  of  semi-solid,  fatty  substance  and 
tufts  of  hair.  Drainage.  (Dr.  Albertin.)  Persistence  of  a  fistula  with  slight  dis- 
charge but  excellent  general  health  and  perfect  functional  result. 


LUNG  TUMORS  151 

useful  also  in  elucidating  the  exact  point  of  origin  of  the 
cyst,  a  thing  particularly  difficult  in  some  cases. 

Careful  observation  of  the  cyst  picture  taken  with  the 
patient  in  different  positions  will  be  very  useful  in  this 
localization. 

If  the  outline  is  clearer,  the  shadow  less  extensive  in  the 
frontal  anterior  position,  for  example,  it  can  be  concluded 
that  the  tumor  is  situated  in  front.  A  new  examination  in 
the  oblique  and  transverse  position  will  confirm  this  finding 
and  it  will  only  be  necessary  to  mark  out  exactly  to  what 
intercostal  spaces  it  corresponds. 

It  is  more  difficult,  in  some  cases,  to  know  whether  it 
is  a  cyst  at  the  base  of  the  lung  or  at  the  convexity  of  the 
liver. 

Bar j  on  has  already  insisted  (Revue  de  Medecine,  October, 
1911)  on  the  great  difficulty  of  this  diagnosis.  In  order 
that  it  may  be  seen  two  things  are  sufficient: 

1.  That  the  cyst  be  situated  as  near  as  possible  to  the 
diaphragm,  either  above  or  below. 

2.  That  there  should  not  exist  at  the  level  of  the  diaphragm 
and  of  the  lateral  diaphragmatic  cul-de-sac  any  clear  space 
discernible  on  the  screen  in  any  of  the  innumerable  positions 
in  radioscopic  examination. 

In  such  a  case  we  must  rely  on  the  height  of  the  superior 
convex  line,  its  mobility,  the  level  of  the  deformation,  the 
examination  of  the  lower  appearance  of  the  liver. 

The  superior  outline  of  cysts  at  the  base  of  the  lung  is  in 
general  more  elevated  than  that  of  cyst  at  the  convexity 
of  the  liver,  and  if  there  is  occasion  to  follow  the  patient 
for  some  time  it  is  seen  that  this  outline  rises  more  quickly, 
and  in  some  months  may  reach  an  intercostal  space,  but 
it  must  also  be  known  that  certain  cysts  at  the  convexity 
of  the  liver  may  rise  as  far  as  the  third  space  in  front.  The 
mobility  of  the  shadow  line  is  much  less  in  the  case  of  a 
pulmonary  cyst  and  may  even  be  completely  abolished. 
On  the  contrary,  it  is  better  retained,  although  restricted, 
in  the  case  of  cyst  at  the  convexity  of  the  liver. 


152  RADIO-DIAGNOSIS:  LUNGS 

The  deformation  is  more  thoracic  in  kmg  cyst;  more 
abdominal  in  liver  cyst. 

Examination  of  the  lower  surface  of  the  liver  after  in- 
flation of  the  stomach  may  show  in  the  case  of  liver  cyst 
a  lowering  of  the  organ  or  the  deformation  of  the  inferior 
contour;  but  all  these  details  have  only  a  relative  value 
and  besides  may  be  lacking.  It  must  be  known  that  in 
certain  cases  it  will  be  absolutely  impossible  to  make  the 
diagnosis  of  localization  by  the  simple  use  of  radioscopic 
examination.  The  greatest  attention  must  be  paid  to  the 
clinical  symptoms  and  in  particular  those  obtained  by 
auscultation  of  the  lung.  The  ascertaining  of  rales,  abnormal 
breathing,  friction  rub  accompanied  by  coughing  and  ex- 
pectoration will  be  in  favor  of  pulmonary  localization. 
Their  absence  will  suggest  rather  a  cyst  at  the  convexity 
of  the  liver. 

Diag?iosis  of  the  variety  of  cysts. — Radiological  examina- 
tion furnishes  little  information  to  establish  this  diagnosis, 
yet  some  secondary  indications  may  be  useful. 

Hydatid  cysts  may  be  multiple,  may  occupy  in  the  lung 
varied  positions  and  remain  completely  independent  of  the 
median  shadow.  They  usually  enlarge  more  rapidly  than 
do  dermoid  cysts.  The  shadow  is  more  homogeneous,  the 
opacity  more  uniform  in  their  entire  extent. 

The  dermoid  cyst  is  single;  by  reason  of  its  mediastinal 
origin  it  remains  always  adherent  to  the  median  shadow. 
Its  position  is,  then,  much  more  uniform.  Its  growth  is 
extremely  slow,  beginning  to  develop  about  the  eighteenth 
or  twentieth  year.  Its  shadow  is  less  homogeneous  than 
that  of  hydatid  cyst.  It  may  contain  teeth,  bones,  tufts 
of  hair,  which  may  either  give  a  visible  picture  or  show 
darker  zones  beside  clearer  ones. 

Finally,  the  clinical  information — previous  history,  de- 
velopment, symptoms,  and  laboratory  tests — can  be  equally 
utilized. 

Hydatid  cysts  emptied  by  vomica. — All  that  has  just  been 
said  applies  to  closed  cysts,  but  when  the  cyst  is  open  and 


LUNG  TUMORS  153 

a  vomica  is  produced,  radioscopic  examination  has  no  longer 
so  great  a  value.  It  does  not  furnish  characteristic  pictures 
and  at  times  does  not  give  any  appreciable  shadow.  Twice 
Bar j  on  examined  hydatid  cysts  of  the  lung  previously  dis- 
charged into  the  bronchi  and  obtained  from  them  no  deci- 
sive indication.  The  shadows  are  much  less  opaque  and 
have  no  more  the  characteristic  spherical  form.  In  this  case, 
fortunately,  clinical  diagnosis  is  easy  because  of  the  previous 
vomica  and  also  from  the  fact  that  from  time  to  time  these 
patients  expectorate  either  pieces  of  hydatid  membrane 
perfectly  recognizable  or  entire  vesicles  in  which  one  finds 
hydatids  and  their  hooks. 

In  conclusion,  radioscopic  and  clinical  examination  sup- 
plement each  other  in  the  diagnosis  of  hydatid  cyst  of  the 
lung.  When  the  cyst  is  closed,  clinical  interpretation  is 
most  difficult,  while  the  radioscopic  examination  shows  a 
characteristic  spherical  shadow  which  carries  conviction. 

On  the  contrary,  when  the  cyst  is  open,  there  is  no  longer 
a  clear  radioscopic  picture  but  only  diffuse  shadows,  while 
clinically  the  expectorated  material  shows  the  origin  of  the 
pulmonary  troubles, 


Radiograph  45.  ANEURYSM  OF  THE  AORTA— ASCENDING  PORTION 
There  is  an  extensiveand  opaque  shadow,  the  rounded  contour  of  which  projects 
into  the  right  lung  but  the  other  part  is  confused  with  the  median  shadow.  The 
outHne  is  not  as  reguhirly  round  as  if  traced  by  a  compass.  It  is  not  homogeneous 
but  shows  thickening  in  places.  It  is  an  aneurysm  of  the  ascending  aorta,  the 
more  opaque  parts  which  are  seen  on  the  outline  corresponding  to  calcareous 
atheromatous  lesions. 


Radiograph  46.     HYDATID  CYST  OF  THE  LEFT  LUNG  AFTER  RUP- 
TURE AND  EVACUATION  BY  VOMICA 

A  diffuse  shadow  in  the  lower  part  of  the  left  lung  is  discerned  but  there  is  no 
contour  accurately  outlined,  no  characteristic  form,  no  spherically  rounded  ap- 
pearance^ Development — voniica  took  place  thiee  and  one-half  months  ago.  Since 
then  the  patient  expectorates  perfectly  recognizable  hydatid  membranes  but  there 
is  no  longer  a  definite  tumor;  no  functional  trouble.    Very  good  general  health. 


PART  V 

PENETRATING  WOUNDS  OF  THE  THORAX  BY  WAR 
PROJECTILES 


CLINICAL  AND  RADIOLOGICAL  STUDY 

NEVER  before  has  there  been  an  opportunity  to  gather 
so  many  clinical  and  radiological  reports  of  pentrat- 
ing  wounds  of  the  thorax.  The  great  European  war  of  1914, 
on  account  of  its  duration,  extent  and  the  tremendous 
effective  forces  employed,  seems  an  inexhaustible  source  of 
study.  These  cases  have  allowed  a  clearer  and  more  ac- 
curate study,  showing  at  the  same  time  the  seriousness  and 
the  benignity  of  these  wounds.  It  has  been  possible  to 
study  with  greater  care  the  symptoms,  complications  and 
development  as  well  as  the  indications  for  operation. 

The  close  connection  which  exists  between  radiological 
exploration  and  war  surgery  is  to-day  demonstrated.  And 
no  branch  of  war  surgery  needs  a  closer  collaboration  of 
surgeon  and  radiologist  than  these  penetrating  wounds  of 
the  chest.  No  wound  requires  a  more  particular  and  com- 
plete radiological  examination. 

This  point  especially  will  be  taken  up.  No  exact  diag- 
nosis can  be  made,  no  useful  discussion  engaged  in  and  no 
conclusion  reached  without  careful  radiological  examina- 
tion of  the  wounded.  This  examination  alone  gives  in- 
formation as  to  the  absence  or  presence  of  a  foreign  body, 
its  topography,  exact  mensuration,  the  reaction  brought 
about  in  the  pleuro-pulmonary  tissues,  and  the  importance 
and  nature  of  the  complications  developed.  Only  the  most 
careful  study  and  discussion  of  the  facts  furnished  by  this 
examination  in  conjunction  with  a  competent  surgeon, 
make  it  possible  to  show  the  indications  and  contra-indica- 
tions  for  operation  in  each  particular  case.* 

I.  Clinical  Study. — 1.  Symptoms  and  diagnosis  of  pene- 

*  The  more  serious  wounds  of  the  thorax  with  sudden  death,  seen  only 
near  the  battlefield  do  not  come  within  the  scope  of  this  study.  It  is  limited 
to  the  wounded  who  can  be  moved  to  the  surgical  units  in  the  rear,  and  whom 
Barjon  had  occasion  to  examine. 

157 


158  RADIO-DIAGNOSIS:  LUNGS 

trating  icounds  of  the  chest. — The  symptoms  produced  by 
penetrating  wounds  of  the  thorax  are  variable.  Some  ap- 
pear at  once,  others  develop  more  slowl3\ 

(a)  Lmjnediate  symptoms. — The  first  is  pain,  which  often 
is  not  severe  and  is  limited  to  sensation  of  shock.  At  other 
times  the  pain  is  very  sharp,  especially  in  cases  of  fractured 
ribs. 

Hemoptysis  is  consequently  one  of  the  earliest  and  most 
constant  symptoms,  but  may  however  be  sometimes  lack- 
mg.  This  early  hemoptj'sis  is  due  to  the  injury  of  blood 
vessels  by  the  passage  of  the  projectiles — an  hemoptysis 
by  rupture.  A  temporary  cough  may  accompany  hemop- 
tysis but  it  too  may  be  lacking. 

Finally,  the  immediate  dj'spncea  is  accompanied  at  times 
by  sensations  of  great  distress. 

But  all  these  signs  may  be  absent  and  a  penetrating 
wound  of  the  thorax  may  pass  unnoticed  especiallj'  if  there 
is  another  more  apparent  wound  to  attract  attention.  A 
wounded  soldier  with  marked  traumatism  of  the  shoulder 
and  arm,  which  required  secondary  amputation,  was  found 
at  the  end  of  two  days  to  have  also  a  penetrating  wound 
of  the  chest. 

(6)  Secondary  symptoms. — These  appear  during  the  first 
few  days  of  the  wound  and  often  later.  They  are  due  to 
reactions  brought  about  by  the  projectile  in  the  pleuro- 
pulmonary  tissue.*  These  reactions  develop  various  physi- 
cal and  functional  symptoms:  sometimes  centers  of  dull- 
ness with  absence  or  with  increase  of  fremitus,  bronchial 
and  pleural  sounds,  or  no  respiratory  sounds.  Associated 
functional  disturbances  are  stitch  in  the  side,  dyspnoea  on 
exertion,  cough,  expectoration  often  streaked  with  blood, 
secondary  hempotysis  due  to  the  pneumonic  reaction  follow- 
ing traumatism.    Tachycardia  is  common. 

In  the  wound  and  wall  there  are  also  special  signs:  sub- 
cutaneous emphysema  under  certain  conditions  especially 

*  Piery  (Lyon  M6  lical,  1914-1916)  has  described  a  hemo-pleuro-pneumonic 
syndrome  with  acute  progress,  which  is  seen  quite  frequently. 


CLINICAL  AND  RADIOLOGICAL  STUDY  159 

when  there  is  fracture  of  the  rib  at  the  same  time  as  pleuro- 
pulmonary  injury.  Sometimes  there  is  a  sHght  oedema  of  the 
wall  which  in  cases  of  infection  may  end  in  a  real  inflamma- 
tion of  the  connective  tissue. 

The  general  health  is  often  affected  indirectly;  furry  con- 
dition of  the  digestive  tract,  rise  in  temperature  ending  at 
times  in  a  high  and  prolonged  fever. 

These  symptoms  taken  together  make  possible  the  di- 
agnosis of  penetrating  wounds  of  the  thorax. 

2.  Form,  development,  complications,  prognosis. — There 
are  two  principal  forms  of  penetrating  wounds  of  the  chest : 
the  perforating  wound  and  the  wound  with  one  or  several 
foreign  bodies  in  the  thorax.  In  the  perforating  wound  the 
projectile  only  goes  through  the  thorax  without  being  ar- 
rested. Most  often  it  is  a  rifle  or  machine  gun  bullet  fired 
at  close  range.  On  account  of  the  proximity  the  initial  veloc- 
ity and  the  force  of  penetration  are  greater  and  the  projectile 
goes  straight  through  the  thorax  without  being  arrested  there. 

This  form  of  wound  is  generally  less  serious,  and  often 
heals  very  quickly  without  complications.  The  bullet  is 
aseptic  from  the  appreciable  increase  in  temperature  to 
which  it  is  subjected  on  account  of  friction.  Its  pointed  and 
regular  form  allows  of  easy  penetration  through  the  clothing 
so  that  pieces  of  clothing  are  seldom  carried  into  the  wound. 
Infection  is  more  unconamon  and  in  a  great  number  of  cases 
there  is  simply  an  aseptic  puncture.  The  wounded  patient 
quickly  recovers,  and  at  the  end  of  two  or  three  months 
nothing  abnormal  is  found  either  on  clinical  or  on  radio- 
scopic  examination.  The  "restitutio  ad  integnun"  is  com- 
plete. 

Sergeant  P.  of  N.  .  .  regiment  of  infantry,  examined  by 
Bar j on,  had  his  thorax  penetrated  from  one  side  to  the  other 
by  two  machine  gun  bullets.  At  the  end  of  several  months 
he  had  no  respiratory  disturbance  and  radioscopic  examina- 
tion showed  a  thorax  absolutely  normal  as  far  as  clearness 
and  functioning  were  concerned. 

Sometimes  there  may  be  seen  even  in  perforating  wounds 


A 


160  RADIO-DIAGNOSIS:  LUNGS 

cases  complicated  with  fracture  of  the  ribs  or  septic  condi- 
tion. Private  C,  studied  by  Barjon  and  Pollosso,  showed 
comminuted  fractures  of  two  ribs  with  bone  and  septic 
fragments.  He  succumbed  to  infection  of  the  wall  and 
pubnonary  gangrene. 

In  penetrating  wounds  with  retention  of  the  projectiles  the 
chances  of  infection  are  more  frequent.  They  are  caused 
most  often  by  bursting  shell  fragments.  The  penetrating 
force  being  less,  the  fragments  lodge  in  the  thoracic  cavity 
and  their  irregular  form  easily  carries  into  the  wound  pieces 
of  clothing  or  equipment.  Consequently  these  wounds  are 
much  more  often  infected.  They  may  give  rise  to  three 
classes  of  wounded:  those  with  serious  complications;  those 
in  whom  the  projectile  causes  disturbance;  and  those  who 
experience  no  discomfort. 

(a)  On  account  of  serious  septic  pleuro-pulmonary  com- 
plications there  is  unfavorable  prognosis  in  a  certain  number 
of  wounded.  These  complications  most  often  develop  as 
acute  febrile  attacks.  They  are  always  serious,  involving 
either  the  lung,  the  pleura,  or  both. 

Pneumonia  and  broncho-pneumonia  will  be  especially 
considered  and  abscess  of  the  lung  which,  without  treatment, 
may  evacuate  either  into  the  bronchi  producing  a  vomica, 
or  into  the  pleura  giving  rise  to  an  empyema;  also  putrid 
infections  of  the  lung  with  foetid  gas  production  and  pul- 
monary gangrene. 

In  the  pleura  a  hemothorax  is  frequently  seen  which  often 
has  a  tendency  to  suppurate  more  or  less  rapidly.  An  in- 
creasing number  of  polynuclears  in  the  hemothorax  contents 
indicates,  according  to  Pohcard  and  Philip,  an  impending 
suppuration.  Pleurisy  which  is  purulent  primarily  or  sec- 
ondarily fills  the  entire  large  pleural  cavity  or  only  a  portion 
(encysted  pleurisy).  Finally,  partial  or  total  pyopneumo- 
thorax is  considered  one  of  the  most  important  pleural  com- 
plications. Mediastinal  abscess,  with  a  serious  prognosis,  as 
reported  by  Mornard  (Soc.  Chirurgie,  August,  1915)  has 
also  been  pointed  out. 


CLINICAL  AND  RADIOLOGICAL  STUDY  161 

In  all  these  complications  radioscopic  examination  is  very 
useful  in  ascertaining  or  confirming  the  location  which 
clinical  signs  have  already  indicated.  As  the  special  radio- 
logical images  in  each  of  these  complications  are  well  known 
and  have  been  described  elsewhere  in  detail,  they  will  not  be 
considered  here. 

(b)  In  other  cases  of  wounds,  the  intra-pulmonary  pro- 
jectile gives  rise  to  less  violent  and  less  acute  symptoms  but 
produces  relapsing  disturbances  either  as  intermittent  or 
chronic  attacks. 

They  occur  as  successive  attacks  of  febrile  pulmonary 
congestion,  recurring  hemoptyses,  chronic  febrile  bronchitis 
with  emaciation  and  excessive  sweating  which  suggests  pul- 
monary tuberculosis,  as  was  the  case  in  a  wounded  patient 
referred  to  Barjon  and  Delore  as  tuberculous. 

(c)  Finally,  the  last  class  includes  all  who  have  no  func- 
tional trouble  from  the  projectile  and  show  no  pulmonary 
reaction  discernible  on  auscultation  and  radioscopic  exam- 
ination. These  classes  will  again  be  considered  in  connection 
with  the  discussion  of  indications  and  contra-indications 
for  operation. 

II.  Radiological  Study. — To  be  useful  this  study  re- 
quires a  series  of  investigations  in  which  radioscopy  and 
radiography  are  used  successively.  The  two  methods  of 
exploration  are  inseparable. 

Nature  of  projectiles. — They  consist  of  metallic  bodies: 
rifle  or  machine  gun  bullets,  shrapnel,  fragments  of  shell 
varying  in  form  and  dimensions.  Sometimes  these  are  ac- 
companied by  secondary  foreign  bodies,  either  broken  off 
by  the  force  of  the  collision  such  as  splinters  of  bone  torn  off 
by  the  fracturing  of  surrounding  bones:  ribs,  sternum, 
clavicles,  scapulae,  vertebral  column;  or  carried  into  the 
wound  by  the  projectile  itself  such  as  pieces  of  clothing  or 
equipment.  The  latter  are  not  usually  visible  on  radio- 
logical examination. 

In  brief,  the  different  examinations  are  as  follows: — 
First  it  will  be  necessary  to  find  the  projectile,  then  deter- 


1G2  RADIO-DIAGNOSIS:  LUNGS 

mine  its  general  position  and  localize  or  mark  it.  Finally,  it 
is  necessaiy  that  indications  for  extraction  be  submitted  to 
the  surgeon. 

1.  Search  for  projectile. — To  ascertain  whether  the  pro- 
jectile has  lodged  in  the  thorax  or  passed  through  it  a  general 
examination  of  the  thorax  is  necessary.  Radioscopy  being 
quicker  and  more  complete  will  be  used  first  for  a  general 
exploration.  Examination  is  made  either  in  the  standing 
or  the  dorsal  decubitus  position  according  to  the  condition 
of  the  wounded.  The  different  positions  for  the  examination 
of  the  thorax  described  in  an  earlier  chapter  should  be  used 
for  discovering  the  projectile.  Occasionally  these  metallic 
foreign  bodies  are  very  visible  on  account  of  the  transparency 
of  the  thorax.  Under  certain  circumstances  they  may  pass 
unnoticed. 

The  projectile  may  be  enclosed  in  a  center  of  hepatization, 
in  a  purulent  accumulation  (pleurisy,  lung  abscess,  etc.) 
which  obscures  its  visibility.  But  the  determining  of  these 
pathological  centers  is  in  itself  important  information.  An- 
other reason  for  the  projectile  not  being  seen  is  its  extremely 
small  size.  Very  small  foreign  bodies  may  pass  unnoticed 
under  the  conditions  of  reduced  visibility  in  radioscopic 
examination. 

Negative  examination  ought  never  to  lead  to  the  conclu- 
sion that  no  foreign  body  is  present,  but  determines  simply 
the  absence  of  a  visible  body. 

On  the  other  hand,  what  has  not  been  seen  radioscopically 
may  appear  on  the  photographic  plate,  which  is  infinitely 
more  sensitive.  When  absolute  certainty  is  desired,  radiog- 
raphy must  be  practised  under  good  conditions.  Instanta- 
neous or  very  rapid  exposure  should  be  used  and  with  forced 
inspiration  so  as  to  produce  the  best  possible  conditions  of 
visibihty.  Too  long  an  exposure  would  give  no  more  cer- 
tainty than  the  radioscope,  because  respiratory  movement 
would  prevent  the  formation  of  any  clear  or  even  visible 
image  of  projectiles  of  small  size. 

2.  Position  of  projectile. — The  presence  of  a  foreign  body 


Radiograph  A.     TRAUMATIC  ENCYSTED  HEMOTHORAX  IN  A  CASE 
OF  OLD  PLEURISY 

The  bullet,  after  passing  through  the  thorax,  lodged  in  the  wall.     Pleurotomy, 
complete  recovery,  thorax  became  entirely  clear  from  apex  to  base. 


Radiograph  B.     PIECE  OF  SHRAPNEL  IN  THE  RIGHT  LUNG 
Long  splinter  of  shell  in  the  posterior  wall.    Right  pleurisy. 


CLINICAL  AND  RADIOLOGICAL  STUDY  163 

having  been  established,  it  is  indispensable  to  use  this  same 
radioscopic  examination  for  information  as  to  the  general 
position:  whether  the  projectile  is  intra- thoracic,  in  the 
lung  or  in  the  pleura;  or  only  in  the  wall. 

Radioscopic  examination  sometimes  suffices;  if  not,  the 
findings  should  be  supplemented  by  exact  measurements. 
It  is  especially  difficult  when  projectiles  are  at  a  tangent  or 
at  the  extreme  base.  For  projectiles  at  a  tangent  it  ought 
to  be  determined  whether  the  projectile  is  found  within 
or  without  the  costal  grill  by  a  series  of  oblique  examina- 
tions with  normal  rays,  used  as  near  as  possible. 

For  projectiles  at  the  extreme  base,  situated  in  the  cul- 
de-sac,  it  is  sometimes  difficult  to  establish  their  location, 
whether  above  or  below  the  diaphragm.  Examinations 
with  forced  inspiration  and  expiration  are  the  most  useful, 
but  are  not  always  possible  on  account  of  the  complete  or 
relative  immobilization  of  the  diaphragm,  A  slight  effu- 
sion or  pleural  exudate  may  further  complicate.  The  pro- 
jectile may  have  caused  a  pleural  reaction  in  the  passage 
and  may  be  fixed  below  the  diaphragm.  If  the  projectile 
or  a  part  of  its  outline  can  be  seen  detached  above  the  dia- 
phragmatic dome  in  any  position,  it  may  be  affirmed  that 
it  is  either  entirely  intra-thoracic  or  partly  included  in  the 
diaphragm. 

Projectiles  at  the  base  may  still  be  free  in  the  pleural 
cavity,  in  which  case  they  are  movable  with  the  different 
changes  of  position  as  reported  by  Gouilloud  and  Arcelin. 

Radioscopic  examination  by  showing  the  presence  of 
pleuro-pulmonary  reactions,  already  mentioned,  is  rather 
in  favor  of  the  existence  of  an  intra-pulmonary  foreign 
body.  Besides  it  fixes  the  general  position  of  the  foreign 
body,  and  indicates  whether  the  projectile  is  found  in  the 
superior  or  inferior  lobe,  whether  it  is  in  the  region  of  the 
interlobar  fissure,  near  the  hilus  and  the  large  blood  vessels, 
etc. ;  information  which  may  be  useful  in  later  discussion. 

3.  Localization. — ^Exact  measurement  of  the  projectile. 
This  process  consists  in  determining  the  exact  location  of 


164  RADIO-DIAGNOSIS:  LUNGS 

the  projectile  and  in  indicating  its  relation  to  the  surrounding 
organs  and  cutaneous  regions  by  which  it  may  be  approached ; 
in  furnishing  by  exact  measurement  the  distance  in  milli- 
meters of  the  projectile,  with  some  natural  or  artificial 
point  of  measurement,  which  may  be  useful  to  the  surgeon 
in  intervention. 

Radiological  methods  of  measurement  are  numerous. 
Many  have  appeared  in  radiological  journals  of  the  past 
two  years.*  Most  are  good,  provided  too  much  is  not  ex- 
pected of  them.  It  is  difficult  for  one  without  experience 
to  choose  from  among  them. 

Calculation  of  depth. — Under  all  these  methods  there  is  one 
basic  fact, — the  determination  of  the  depth  of  the  projectile. 
This  essential  measurement  is  obtained  in  different  ways. 
One  of  the  simplest,  which  requires  no  special  apparatus, 
is  a  double  exposure  on  the  same  plate. 

The  tube  being  placed  at  a  given  height  above  the  plate, 
two  successive  half  exposures  are  made.  For  the  second 
exposure  the  tube  is  shifted  a  few  centimeters  horizontally. 
Two  distinct  images  of  the  projectile  are  thus  obtained  on 
the  plate  and  the  distance  between  them  can  be  exactly 
measured  with  a  compass.  Three  facts  are  thus  known: 
the  height  of  the  anticathode  above  the  plate  (H);  the 
shifting  of  the  anticathode  for  the  second  exposure  (D); 
and  finally  the  distance  between  the  two  foreign  bodies  on 
the  plate  (d). 

By  drawing  straight  lines  which  represent  in  the  space 
the  direction  of  the  rays,  similar  triangles  with  approximat- 
ing  apices   are   obtained.     By   geometric   calculation   the 

H  X  d 

formula  is  established  x  =  which  gives  the  distance 

D4-  d 
from  the  foreign  body  to  the  plate  in  known  dimensions. 
In  this  way  the  first  fundamental  fact  is  obtained  which 

*  See  particularly  the  following  articles:  Belot  and  Fraudet,  Proc4d6  de 
rep^rage  des  projectiles  (Joum.  de  Radiologie  et  d'filectrologie,  Jan.-Feb. 
1916).    Albert  WeUl,  Paris  Medical,  Feb.  5,  1916. 


CLINICAL  AND  RADIOLOGICAL  STUDY  165 

indicates  in  depth  the  location  in  the  body  of  the  foreign 
body  sought  for. 

Surgical  application. — This  result,  to  be  of  use  later  to 
the  surgeon,  ought  to  be  practically  applied.  The  actual 
methods  used  can  be  grouped  into  three  main  classes  ac- 
cording to  the  way  in  which  this  localization  is  done:  first, 
by  means  of  instruments  (instrumental  methods),  second, 
by  means  of  diagrams,  marked  plans,  stereoscopic  pictures 
(graphic  methods),  finally  by  locating  projectiles  in  relation 
to  certain  definite  anatomical  landmarks  (anatomical 
methods) . 

The  instrumental  methods  seem  to  be  most  in  use  to-day. 
The  greater  part  are  based  on  the  use  of  a  directing  com- 
pass, indicating  usually  in  the  course  of  intervention  the 
direction  and  the  distance  of  the  foreign  body. 

The  earliest  of  these  instruments  is  the  Hirtz  compass, 
which  is  excellent.  It  is  on  his  principle  that  all  the  others 
are  based.  It  has  the  disadvantage  of  being  delicate,  of 
necessitating  minute  and  long  investigation,  and  of  re- 
quiring the  construction  of  a  complicated  diagram.  In 
spite  of  all  this  it  is  still  very  much  in  use  and  is  a  very  exact 
and  excellent  instrument. 

Among  the  others  is  the  Saissi  compass  which  has  been 
used  by  Henri  Beclere  and  which  Marion  recommends. 

This  instrument,  however,  has  been  simplified  and  only 
the  Debierne  com.pass,  the  Massiot  compass  and  the  sector 
guide  of  Grandgerard  will  be  considered.  These  three 
instruments  are  based  on  the  same  principle.  It  consists 
in  taking  the  foreign  body  as  the  center  of  a  sphere.  This 
sphere  is  represented  by  an  arc  of  a  metalUc  circle  on  which 
a  movable  rod  glides;  this  makes  one  of  the  rays.  TMiatever 
its  position,  this  ray  is  always  directed  toward  the  center 
and  indicates  the  direction  and  distance.  The  advantage 
to  the  surgeon  is  to  be  able  to  choose  from  among  all  these 
positions  the  one  which  seems  the  most  favorable. 

The  graphic  methods  are  also  quite  accurate,  but  their 
disadvantage  is  that  they  do  not  give  directly  any  surgical 


A 


166  RADIO-DIAGNOSIS:  LUNGS 

application.  With  an  operator  accustomed  to  the  reading 
and  interpreting  of  graphics,  with  the  continuous  aid  of 
radiography,  this  procedure  gives,  however,  good  resuUs. 
Nogier  has  proposed  a  simple  and  accurate  graphic  method. 

In  this  class  methods  may  be  included  which  make  use  of 
stereoscopic  pictures,  so  little  used.  However,  a  simplified 
stereoscope  described  by  Chassard  and  Lahousse  allows 
of  the  numerical  determination  of  distance,  which  is  de- 
pendable localization. 

Anatomical  methods  are  more  truly  surgical.  They 
estimate  the  exact  location  of  the  projectile  in  relation  to 
one  or  several  anatomical  marks.  They  have  the  advantage 
of  allowing  greater  freedom  to  the  surgeon  who  approaches 
the  foreign  body  thus  located,  in  the  way  which  seems  best. 
Arcelin  has  used  one  of  these  methods  with  success  in  a 
large  number  of  cases.* 

Difficulty  of  applying  these  methods  in  pulmonary  cases 
on  account  of  the  mobility  of  the  lungs. — It  is  first  of  all 
very  important  to  note  that  conditions  are  quite  different 
for  intrapulmonary  projectiles,  on  account  of  the  very 
great  mobility  of  the  lung.  This  mobility  is  considerable 
and  the  movement  of  the  foreign  body  in  inspiration  and 
expiration  may  amount  to  several  centimeters.  These 
movements  are  quite  appreciable  towards  the  apex  where 
they  easily  measure  a  centimeter  and  much  more  important 
toward  the  base  where  the  movement  not  uncommonly  is 
from  two  to  three  centimeters. 

To  this  mobility  is  added  that  of  the  thoracic  wall,  which 
is  very  extensive,  especially  in  front.  The  mobility  of  the 
lung,  however,  is  far  from  being  equal  to  that  of  the  wall, 
especially  if  no  adhesions  are  present. 

An  attempt  has  been  made  to  distinguish  between  ad- 
herent and  immobile  lungs  and  free  mobile  lungs.  This 
distinction  has  not  the  practical  value  which  it  is  supposed 
to  have. 

*  Arcelin.  Localisation  anatomique  des  projectiles  de  guerre.  Paris 
Medical,  February  5,  1916. 


Radiograph  A 
Intra-piilmonary  rifle  bullet  without  appreciable  reaction. 


Radiograph  B 
Displacement  in  inspiration  and  expiration  of  an  intra-pulmonary  polygonal 
piece  of  shell  and  a  triangular  indicator  on  the  anterior  wall. 


CLINICAL  AND  RADIOLOGICAL  STUDY  167 

In  fact,  limited  adhesions,  which  are  most  common,  do 
not  immobilize  the  lung;  it  continues  to  be  moved,  pulled 
by  the  wall  to  which  it  is  attached.  Displacement  will  be 
more  limited  if  the  adhesions  are  posterior,  but  its  extent 
will  still  be  considerable  if  the  adhesions  are  anterior.  In 
reality,  displacement  of  the  wall  is  very  extensive  during 
inspiration  and  expiration.  It  is  easily  demonstrated  by 
making  a  double  instantaneous  exposure  on  the  same  plate 
in  these  two  extreme  positions.  The  angle  of  displacement 
described  by  the  ribs  continues  to  enlarge  more  and  more, 
from  the  fixed  dorsal  part  to  the  mobile  sternal  portion. 
Scarcely  ever,  except  in  pleurisy,  would  immobilization 
occur  and  there  but  seldom,  and  even  in  total  symphysis 
absolute  immobilization  does  not  exist.  Two  practical 
conclusions  may  be  drawn  from  these  facts. 

The  first  is  that  measurement  of  the  depth  of  an  intra- 
pulmonary  projectile  by  the  method  of  double  exposures 
on  the  same  plate  is  subject  to  certain  errors.  In  order 
that  the  measurement  be  accurate  it  is  necessary  that  both 
exposures  be  made  in  exactly  the  same  respiratory  position, 
of  which  we  can  never  be  certain.  It  is  often  impossible  to 
control  patients  and  to  keep  them  even  for  some  moments 
in  forced  inspiration  or  expiration.  Such  patients  breath 
in  their  own  way  and  it  is  impossible  to  regulate  them. 
Even  in  those  cases  which  are  closely  observed  and  where 
there  is  co-operation,  it  can  never  be  certain  that  two  ex- 
posures made  in  succession  with  a  definite  interval  elapsing 
will  be  found  exactly  in  the  same  condition.  Inspiration, 
for  example,  may  be  a  little  deeper  in  one  than  in  the  other. 

Now,  an  inspiratory  displacement  of  some  millimeters  and 
that  caused  by  the  moving  of  the  tube  must  either  be  added 
or  deducted;  in  every  case  they  will  distort  the  true  estimate 
of  the  depth  of  the  projectile,  since  it  is  based  on  the  meas- 
urement of  this  displacement. 

It  is  not  possible,  therefore,  to  obtain  any  measurement  of 
foreign  bodies  in  the  lung  so  accurately  as  when  they  are 
lodged  in  an  immobile  portion  of  the  body  or  limbs. 


168  RADIO-DIAGNOSIS:  LUNGS 

A  second  conclusion  which  may  be  drawn  is  that  it  is 
necessary  in  the  king  to  distinguish  between  localization  and 
extraction.  In  the  fixed  portions  of  the  bodj^  conditions  are 
not  changed  between  localization  and  extraction.  Points 
of  measurement  and  their  distance  in  relation  to  the  pro- 
jectile remain  always  fixed.  In  the  lungs  this  is  not  the  case. 
At  the  time  of  intervention  conditions  become  different  from 
what  they  were  at  the  time  of  localization,  and  displacement 
of  the  foreign  body  follows  which  may  become  important. 

From  anesthesia  respiratory  conditions  are  already 
changed.  Even  if  the  changes  are  unimportant,  they  be- 
come more  important  from  the  production  of  a  pneumothorax 
which  upsets  all  the  relations  of  the  lungs. 

Objection  will  be  made  that  the  lungs  are  always  attached 
to  the  wall  in  a  slight  degree.  This  fixation  is  sufficient  for 
the  surgeon  because  he  can  keep  under  his  fingers  the  portion 
of  lung  which  he  wishes  to  explore,  but  from  a  physiological 
point  of  view  it  is  only  illusory;  it  only  decreases  displace- 
ment; it  does  not  suppress  it. 

The  surgeon  may  immediately  come  upon  the  projectile, 
but  this  will  be  because  of  his  surgical  instinct  and  keen 
sense  of  touch  and  not  because  the  foreign  body  was  in- 
dicated so  many  millimeters  in  such  a  direction;  manifestly 
this  could  not  be  indicated  on  account  of  the  pulmonary 
retractility.  If  the  surgeon  is  fortunate  enough  to  extract 
the  projectile  in  spite  of  obstacles,  it  is  certain  that  mobility, 
which  may  often  be  a  hindrance,  is  not  an  insurmountable 
obstacle  to  successful  intervention.  Certain  operative 
technique,  that  of  Duval  for  instance,  is  even  based  on  this 
mobilit3\ 

This  does  not  imply  that  all  localization  is  useless.  It  is 
only  intended  to  show  that  too  great  exactness  is  illusory 
and  almost  impossible  to  obtain  in  foreign  bodies  in  the  lung 
and  that  besides,  it  is  not  indispensable  in  such  cases  in  order 
to  bring  about  good  surgical  intervention. 

The  function  of  the  radiologist. — In  determining  the  use 
of  radiology  to  the  surgeon  distinction  must  be  made  as  to 


CLINICAL  AND  RADIOLOGICAL  STUDY  169 

whether  operation  is  necessary  on  account  of  pleuro-pul- 
monary  complications  or  only  because  of  the  presence  of  a 
projectile. 

a.  In  cases  of  complication,  especially  septic  complication, 
as  total  or  encysted  purulent  pleurisy,  pyopneumothorax, 
hemothorax,  lung  abscess,  pulmonary  gangrene,  etc.,  the  pro- 
jectile becomes  of  secondary  importance.  The  surgeon  must 
be  informed  as  to  the  location  and  extent  of  the  accumulation 
to  be  opened  and  drained  in  order  that  he  may  decide  the 
method  of  approach.  Sometimes  in  evacuating  the  collec- 
tion, the  foreign  body  will  eliminate  itself  either  immediately 
or  after  some  days.  If  it  is  not  eliminated,  the  complication 
should  be  allowed  to  clear  up;  then  the  projectile  should  be 
considered  as  in  the  case  presently  to  be  studied. 

b.  Cases  where  there  is  present  in  the  lung  a  projectile 
which  does  or  does  not  bring  on  a  local  reaction  and  the  ex- 
traction only  of  which  is  to  be  considered. 

An  exact  topography  of  the  foreign  body  will  be  made 
first.  At  the  same  time  the  presence  or  absence  of  pulmonary 
reaction  will  be  indicated  as  a  dark  zone  around  the  pro- 
jectile, diminution  of  clearness  of  the  entire  lung  or  of  the 
lobe  containing  the  metal  fragment,  decrease  of  pulmonary 
expansion  and  of  the  amplitude  of  respiratory  movements. 
All  these  facts  are  useful  for  the  discussion  of  indication  or 
contra-indication  for  operation. 

Localization  must  be  carefully  considered.  It  has  been 
shown  that  in  practice  accurate  determination  is  doubtful 
and  not  at  all  necessary.  Nevertheless  in  this  study  all 
possible  care  should  be  employed  and  in  making  this  localiza- 
tion each  one  should  use  the  process  to  which  he  is  accus- 
tomed, which  he  knows  best  how  to  apply  with  the  minimum 
of  errors. 

Bar j  on  considers,  however,  that  it  is  better  not  to  be  con- 
tent with  any  one  indication,  but  that  it  is  useful  to  deter- 
mine the  location  and  the  depth  of  the  projectile  in  relation 
to  several  points  in  the  thoracic  wall.  A  posterior,  an 
anterior  and  a  lateral  point  are  ordinarily  enough,  but  it  is 


170  RADIO-DL\GNOSIS:  LUNGS 

easy  to  take  others.  By  this  method  the  surgeon  is  left  a 
choice  in  approaching  the  foreign  body.  Radioscopic  meas- 
urement may  be  used  to  establish  these  facts  quickly  with 
sufficient  accuracy. 

The  method  of  Hu-tz  and  Gallot  described  by  Gallot  in 
the  Archives  d'Electricit<5  medicale  (April,  1915,  p.  115)  gives 
readily  and  without  an}'  calculation  the  measurement  of 
depth  by  means  of  a  pierced  screen  and  a  plumb  line. 

To  facilitate  the  work,  when  the  wounded  are  strong 
enough,  which  is  frequent,  Barjon  has  modified  this  appara- 
tus so  as  to  take  measurements  in  the  upright  position. 
He  has  replaced  the  plumb  line  by  a  solid  graduated  rod 
sliding  into  a  cylinder  fastened  in  front  of  the  opening  and 
always  kept  perpendicular  to  the  surface  of  the  screen,  con- 
sequently in  the  axis  of  the  normal  rays  of  incidence. 

This  procedure  is  simple,  convenient  and  quick;  it  does 
away  with  all  errors  in  calculation  and  estimate  of  distance 
and  displacement  of  the  anticathode  which  does  not  even 
have  to  be  taken  into  account. 

One  process  alone  would  appear  rational, — examination 
on  the  radioscopic  table.  The  operating  table  should  also 
be  a  radioscopic  table  so  that  brief  examination  can  be  made 
at  intervals  and  the  surgeon  can  be  told  just  what  location 
the  foreign  body  occupies  in  relation  to  forceps  or  any  other 
metallic  instrument  placed  in  the  wound  in  a  convenient 
manner.  It  is  only  necessary  to  supply  a  table  with  sufficient 
means  of  protection  to  safeguard  the  surgeon  and  his  assist- 
ants, to  use  the  least  possible  amount  of  X-rays  and  during 
very  short  lengths  of  time  on  account  of  the  real  danger  of 
these  examinations.* 

Other  means  of  localization  and  direction  may  give  as  good 
results  in  the  hands  of  experienced  operators.  Barjon  em- 
phasizes once  more  that  the  best  method  is  that  which  one 
knows  best  and  has  practised  most. 

III.  Course  of  Procedure.    Indications  and  Contra- 

*  To  the  Wullyamoz  table  and  the  modified  model  of  Arcelin  attention  is 
especially  called. 


Radiograph  C 
Large  piece  of  shell,  intra-pulmcnary,  very  well  endured  for  ten  months.     No 
appreciable  reaction,  no  functional  disturbance. 


Radiograph  D 
Large  piece  of  shell,  intra-pulmonary,  with  important  reaction.     Obscurity  of 
entire  apex  of  the  lung. 


CLINICAL  AND  RADIOLOGICAL  STUDY  171 

Indications  for  Operation. — The  mode  of  procedure  in 
penetrating  wounds  of  the  thorax  is  highly  interesting  to  the 
radiologist,  because  in  discussing  the  question  of  indications 
and  contra-indications  for  operation,  aside  from  clinical 
facts,  medical  and  surgical,  an  important  place  ought  to  be 
given  to  radiological  findings. 

It  is  necessary,  therefore,  that  the  radiologist  be  in  a  posi- 
tion to  appreciate  exactly  the  value  of  the  information  ob- 
tained from  his  examination. 

There  are  three  groups  of  facts: 

a.  Positive  and  urgent  indication. — The  first  group  in- 
cludes febrile  infected  patients  with  the  appearance  of  being 
seriously  ill.  Radioscopic  examination  shows  that  the 
center  of  infection  or  suppuration  is  intra- thoracic.  It 
shows  extensive  pathological  shadows,  of  variable  form 
and  appearance.  The  images  indicate  the  presence  either 
of  a  pleural  infection:  total  or  encysted  purulent  pleurisy, 
hemothorax;  or  of  a  pleuro-pulmonary  infection :  pyopneumo- 
thorax, pleuro-pulmonary  gangrene;  or  of  a  definite  pul- 
monary accumulation:  lung  abscess.  In  all  these  cases 
indication  for  operation  is  not  only  positive  but  urgent. 
It  is  a  case  in  which  surgery  is  indicated  for  pleuro-pulmonary 
septic  complications,  which  are  already  well  established  and 
recognized,  rather  than  surgery  which  has  to  do  with  war 
projectiles. 

If  after  intervention  the  projectile  is  not  discharged,  the 
wounded  come  into  one  of  the  following  groups: 

b.  Positive  indication,  not  urgent. — In  the  second  group 
are  included  all  those  wounded  who  without  any  symptoms 
of  serious  infection  or  of  apparent  centers  of  suppuration 
have  intrapulmonary  projectiles  which  they  do  not  stand 
very  well. 

In  these  patients  there  are  seen  clinically  slight  attacks 
of  pulmonary  congestion,  or  small  pleural  effusions,  re- 
curring hemoptyses,  bronchitic  attacks.  Examination  of 
the  thorax  shows  diminution  of  resonance  or  even  a  definite 
dullness,  modifications  of  sounds,  increase  or  disappearance; 


172  RADIO-DL\GNOSIS:  LUNGS 

rdles,  ronchi,  fremitus,  respiration  a  little  shallow,  most 
often  no  respiratory  sounds. 

From  a  functional  point  of  view  these  patients  cough 
and  expectorate,  have  dyspnoea,  especially  on  exertion, 
tachycardia,  thoracic  pains  brought  on  or  increased  by 
coughing  and  walking.  General  health  is  poor;  some  have 
intermittent  febrile  attacks,  others  grow  pale  and  thin;  some 
have  been  considered  tuberculous  until  radioscopic  exam- 
ination disclosed  the  presence  of  a  projectile. 

Radiological  examination  not  only  shows  the  presence 
of  the  projectile  and  locates  it,  but  furnishes  also  valuable 
indications  which  show  considerable  diminution  in  the 
functional  value  of  the  lung  affected. 

Sometimes  there  is  diffuse  obscurity,  not  very  extensive, 
limited  to  the  area  around  the  projectile  or  immediate 
vicinity.  Sometimes  the  obscurity  extends  to  all  the  lobe 
involved  and  sometimes  even  to  the  entire  lung.  Vesicular 
expansion  produced  by  forced  inspiration  or  by  coughing 
has  entirely  disappeared  while  it  remains  in  the  other 
lung. 

The  extent  of  the  excursion  of  the  diaphragm  in  respira- 
tory movements  is  limited;  at  times  added  pleural  exudates 
obscure  the  base,  partially  or  totally  effacing  the  contour 
of  the  diaphragm,  immobilizing  it  and  filling  up  the  costal 
sinus. 

In  all  cases  of  this  class  it  is  clear  that  the  projectile  is 
the  only  cause  of  all  the  trouble.  There  is  still  positive 
indication  for  operation  but  it  is  not  urgent.  The  location 
of  the  foreign  body  and  the  reactions  produced  must  be 
be  studied  all  the  time.  Once  all  this  knowledge  has  been 
collected,  intervention  can  be  undertaken. 

c.  Debatable  indications. — Finally,  the  third  and  last 
group  includes  foreign  bodies  which  are  well  tolerated.  A 
certain  percentage  of  the  wounded  show  perfect  tolerance. 
One  soldier  was  known  to  have  had  a  large  piece  of  shell 
(25  by  15  mm.)  in  the  right  lung  for  ten  months,  without 
experiencing  the  least  discomfort;  there  was  no  apparent 


CLINICAL  AND  RADIOLOGICAL  STUDY  173 

physical  or  functional  disturbance  on  clinical  or  radioscopic 
examination. 

Others  possess  less  perfect  tolerance  and  have  very  slight 
functional  troubles,  such  as  dyspnoea  on  slight  exertion, 
palpitation,  thoracic  pain,  nervous  reflexes;  but  have  no 
cough,  no  physical  sign  on  auscultation,  no  febrile  reaction. 
Bar j  on  believes  that  in  some  of  these  cases  suggestion  may 
play  a  part  in  causing  these  slight  disturbances. 

This  third  class  includes  more  debatable  cases,  which 
from  the  point  of  view  of  intervention,  are  acted  on  posi- 
tively by  some  surgeons,  negatively  by  others. 

Marion  and  Duval  believe  positively  in  intervention.  In 
their  opinion  every  intra-pulmonary  projectile  ought  to  be 
taken  out  because  it  may  become  the  starting  point  of  a 
secondary  infection,  and  because  there  is  always  a  small 
center  of  suppuration  around  the  projectile. 

Certainly  a  projectile  left  in  the  lung,  especially  if  it  is  of 
any  size,  is  something  abnormal,  anti-surgical  and  conse- 
quently disturbing.  It  is  a  solution  which  is  not  entirely 
satisfactory.  From  a  military  point  of  view,  according  to 
many,  every  man  who  knows  he  has  an  intra-pulmonary 
projectile  is  lost.  This  argument,  which  may  have  some 
reason,  is  not  actually  a  medical  rule  and  will  lose  its  value 
after  the  war, 

A  second  class  of  surgeons  do  not  believe  in  intervention. 
Certain  projectiles  are  very  well  endured  for  a  long  time. 
Cases  are  quoted  of  fourteen  to  eighteen  months'  duration 
without  any  disturbance.' 

Intervention  is  not  without  danger.  Cases  of  death  have 
been  reported.    (Leriche's  case  with  negative  autopsy.) 

Contra-indications. — Particular  cases  of  contra-indication 
have  been  specified  by  some  surgeons.  Mauclaire  points 
out  the  deep  location  of  the  projectile  in  the  region  of  the 
large  hilus  blood  vessels,  which  increases  operative  risk. 
Quenu  points  out  as  contra-indication  multiplicity  of  pro- 
jectiles which  complicates  operative  technique. 

Finally,  not  all  surgeons  are  of  the  same  opinion  regarding 


174  RADIO-DLVGNOSIS:  LUNGS 

the  local  condition  of  the  lung  surrounding  the  foreign  body. 
Some  assert  there  is  always  a  small  center  of  suppuration. 
Others  find  in  certain  cases  no  trace  of  infection  or  sup- 
puration. According  to  them,  the  projectile  has  been  found 
in  process  of  encystment  in  dense  or  entirely  sclerosed  pul- 
monary tissue.*  This  finding  has  a  gi'eat  value  because  it 
shows  that  certain  projectiles  may  become  encysted  in  the 
lung,  be  surrounded  by  sclerous  tissue  and  perhaps  later 
by  calcareous  infiltration  as  in  a  healed  tubercle.  In  that 
case  they  may  be  tolerated  mdefinitely.  It  is  clear  that 
to  judge  this  question  well  a  lapse  of  some  years  is  necessary. 
Conclusion. — At  present  it  must  be  concluded  that  no 
absolute  rule  can  be  admitted.  It  is  not  only  a  question 
of  projectiles  and  operative  technique;  the  wounded,  the 
physicians  and  surgeons  must  be  considered.  The  decision 
is  a  matter  of  clinical  sense,  of  judgment,  wisdom  and  pro- 
fessional conscience. 

NOTE 

By  major  J.  S.  SHEARER 

WAR  DEPARTMENT,    MILITARY   SCHOOL    OF   ROENTGENOLOGY,   CORNELL 
UNIVERSITY  MEDICAL  COLLEGE,  NEW  YORK  CITY 

AFTER  consultation  with  the  Director  of  Roentgenology, 
American  Expeditionary  Forces,  Major  James  T.  Case, 
the  Surgeon  General's  Office  decided  to  adopt  certain  stand- 
ard methods  of  localization.  Of  these  three  may  be  described 
as  simple  depth  methods,  giving  the  distance  from  the  skin 
to  the  position  of  the  projectile  at  the  time  of  observation 
in  a  vertical  direction.  Three  methods  were  also  adopted 
which  give,  in  addition  to  the  depth,  some  indication  of 
surgical  approach  or  an  indicator  during  operation. 

Two  of  these  will  doubtless  find  considerable  value  in  chest 
lesions.     These  are   (1)   the  profondometer:  this  depends 

*  Belot  (Journal  de  Radiologie  et  d'filectrologie,  May-June,  1916)  shows 
radiographically  the  formation  of  these  fibrous  cicatrices  in  the  presence  of 
a  projectile. 


NOTE  175 

upon  the  establishment  of  three  Hnes  of  sight  through  the 
body  and  the  projectile  and  the  reproduction  of  the  contour 
of  the  body  in  the  plane  of  these  lines,  which,  in  connection 
with  the  cross  section  anatomy  gives  the  surgeon  an  ap- 
proximate depth  from  a  variety  of  directions  and  a  reason- 
ably clear  idea  of  the  important  organs  to  be  penetrated 
or  displaced  in  an  attempt  to  remove  the  body. 

The  other  method  is  the  well-known  Hirtz  compass  which 
in  a  great  majority  of  cases  will  be  a  favorite  of  the  surgeons. 
It  will  be  possible  in  most  of  the  chest  lesions  to  acquire 
the  data  necessary  for  operating  the  compass  by  a  fluoro- 
scopic examination  which  will  be  very  much  more  expedi- 
tious than  the  photographic  method.  This  will  undoubt- 
edly greatly  extend  the  usefulness  of  the  compass  and 
broaden  its  appUcation. 

Provision  is  also  made  for  intermittent  control  so  that 
the  Roentgenologist  may,  in  case  of  need,  quickly  make 
fluoroscopic  observation  in  order  to  render  assistance  to  the 
surgeon  in  case  of  difficulty.  It  is  hoped  that  by  co-operation 
on  the  part  of  the  Roentgenologist  and  the  surgeon  that  the 
simple  methods  adopted  will  serve  the  purpose,  especially 
if  the  Roentgenologist  will  endeavor  to  give  accurate  ana- 
tomical information  in  addition  to  the  more  geometric 
localization. 


INDEX 


Abnormal  images,  8 
Abscess  of  the  lung,  108 
Acute  active  oedema,  100 
Acute  bronchitis,  85 
Acute  infectious  pulmonary- 
processes,  102 
Adenopathy,  tracheo-bronchial, 

89 
Adhesions,    in    dry    diaphrag- 
matic pleurisy,  44 
Apex,  appearance  of  in  pleurisy, 

16 
Apices,  examination  of,  7,  120 
Artificial  pneumothorax,  72 
Artificial  pneumothorax,  radio- 

scopic  treatment  during,  75 
Atelectasis,  115 

Balance  movement,  60 

Bases,  radioscopic  characteris- 
tics common  to  congestion  of, 
100 

Bronchial  affections,  85 

Bronchi,  diagnosis  of  foreign 
bodies  in,  84 

Bronchi,  dilatation  of,  86 

Bronchi,  foreign  bodies  in,  81 

Bronchi,  infection  from  foreign 
bodies  in,  83 

Bronchi,  radiological  study  of, 
79 

Bronchi,  tolerance  to  foreign 
bodies  in,  83 

Bronchial  affections,  85 

Bronchial  stenosis,  86 


Bronchitis,  acute,  85 
Bronchitis,  chronic,  85 
Broncho-pneumonia,  106 
Broncho-pneumonia,        lobular 

form,  107 
Broncho-pneumonia,      pseudo- 

lobar  form,  106 

Calculation    of  depth  of    pro- 
jectile, etc.,  164 
Cancer  of  the  lung,  142 
Cancer  of  the  lung,   primary, 

143 
Cancer  of  the  lung,  lobar,  143 
Cancer  of  the  lung,  hilus,  144 
Cancer  of  the  lung,  secondary, 

144 
Cancer  of  the  lung,  nodular,  144 
Cancer  of  the  lung,  diffuse,  145 
Cancer  of  the  pleura,  148 
Cavities,  pulmonary,  135 
Chronic  bronchitis,  85 
Chronic  passive  oedema,  100 
Chronic   pulmonary   processes, 

113 
Circumscribed     and     encysted 

pleurisy,  34 
Clinical   study   of   penetrating 

wounds  of  thorax,  157 
Clinical  and  radiological  study 

of    penetrating    wounds    of 

thorax,  157 
Complications  in  tuberculosis, 

136 
Congestions,  99 


177 


178 


INDEX 


Congestion  of  bases,  radioscopic 
characteristics    common    to, 
100 
Congestion,  passive,  100 
Congestion,  primary'  active,  99 
Congestion,    secondary   active, 

100 
Contra-indications    for    opera- 
tion in  penetrating  womids, 
etc.,  173 
Cured  tuberculosis,  140 
Curve  of  Damoiseau,  18,  23 
Cysts,  diagnosis  of  localization 

of,  150 
Cysts,  diagnosis  of  variety  of, 

152 
Cysts,  differential  diagnosis  of, 

149 
Cj'^sts,  emptied  by  vomicas,  152 
Cysts,    hydatid    and    dermoid, 
148 

Damoiseau,  curve  of,  18,  23 

Depth  of  projectile  in  penetrat- 
ing wounds  of  thorax,  etc., 
164 

Dermoid  cysts  of  thorax,  148 

Detailed  examinations,  7 

Development  and  retrogression 
of  effusion,  23 

Diagnosis  of  cysts,  localization, 
150 

Diagnosis  of  effusion  in  children, 
difficulty  of,  28 

Diagnosis  of  effusion  by  radi- 
ology, 24 

Diagnosis  of  foreign  bodies  in 
bronchi,  84 

Diagnosis  of  pneumonia  in  chil- 
dren, 102 


Diagnosis  of  variety  of  cysts, 

152 
Diagnosis  of  type  of  pleurisy, 

28 
Diaphragm,  examination  of,  8 
Diaphragm,  stud}'  of,  20 
Diaphragm,     theory    of    flat- 
tening of,  62 
Diaphragmatic  pleurisy,  40 
Differential  diagnosis,  91,  149 
Dilatation  of  the  bronchi,  86 
Displacement  of  heart  and  me- 
diastinum, 22 
Dorsal  position,  4 
Dry     diaphragmatic     pleurisy, 

44 
Dry  mediastinal  pleurisy,  49 
Dry  pleurisy,  31 

Effusion,  development  and  re- 
trogression of,  23 

Effusion  in  children,  difficulty 
of  diagnosis,  28 

Effusion,  diagnosis  of  by  radi- 
ology, 24 

Effusion  in  interlobar  pleurisy, 
35 

Effusion,  large  total,  26 

Effusion  in  mediastinal  pleurisy, 
46 

Effusion  in  pleurisy,  15 

Effusion,  pulmonary  lesions  as- 
sociated with,  26 

Effusion,  upper  limit  of,  16 

Effusions  in  retrogression,  28 

Effusions,  slight,  28 

Emphysema,  pulmonary,  113 

Empyema,  development,  54 

Empyema,  location,  54 

Empyema,  origin,  54 


INDEX 


179 


Empyema,  radioscopic  diagno- 
sis, 54,  55 
Encysted  pneumothorax,  70 
Examination     of     apices,     7, 

120 
Examination,  complete,  6 
Examination,  detailed,  7 
Examination  of  diaphragm,  8 
Examination  of  hilus,  7,  123 
Examination   of  interlobes,   7, 

124 
Examination  of  lungs,  8 
Examination,  method  of  proce- 
dure for,  6 
Examination  of  ribs,  8 
Examination  of  sinuses,  7 
Examination  of  thoracic  cavity 
and  heart,  etc.,  125 

False  recovery  through  vomica, 

37 
Flattening  of  diaphragm,  theory 

of,  62 
Foreign  bodies  in  the  bronchi, 

81 
Foreign  bodies  in  the  bronchi, 

diagnosis  of,  84 
Foreign  bodies  in  the  bronchi, 

infection  from,  83 
Foreign  bodies  in  the  bronchi, 

location  of,  82 
Foreign  bodies  in  the  bronchi, 

mobility  of,  82 
Foreign  bodies  in  the  bronchi, 

nature  of,  81 
Foreign  bodies  in  the  bronchi, 

visibihty  of,  82 
Foreign    bodies,    tolerance    of 

bronchi  to,  83 
Frontal  position,  1 


Gangrene,  pulmonary.  111 
Glands,  radioscopic  distinction 

between  groups  of,  89 
Glands,  radioscopic  image  of,  91 

Heart,  displacement  of,  22 
Heart  in  pulmonary  tuberculo- 
sis, examination  of,  125 
Hilus,  examination  of,  7,  123 
Hilus   open    space    of    pleura, 

50 
Hilus  region,  pleurisy  of,  49 
Hydatid  cysts  of  lung,  148 

Images,  abnormal,  8 

Images,  normal,  1 

Indications  for  operating  in 
penetrating  wounds,  etc.,  171 

Infarct,  101 

Infection  from  foreign  bodies 
in  bronchi,  83 

Interlobe,  sclerosis  of,  39 

Interlobar  pleurisy,  34 

Interlobar  pleurisy  with  effu- 
sion, 35 

Interlobes,  examination  of,  7, 
124 

Large  cavity,  pleurisy  of,  15 

Large  total  effusion,  26 

Limited  or  encysted  pneumo- 
thorax, 70 

Lobular  broncho-pneumonia, 
107 

Localization  of  projectiles,  etc., 
163 

Location  of  foreign  bodies  in 
bronchi,  82 

Lung  abscess,  108 

Lung,  cancer  of,  142 


180 


INDEX 


Lung,  hydatid  cyst  of,  148 
Lung,  primary  cancer  of,  143 
Lung,  primary  cancer  of,  lobar, 

143 
Lung,  primary  cancer  of,  hilus, 

144 
Lung,     secondary    cancer     of, 

144 
Lung,  secondary  cancer  of,  nod- 
ular, 144 
Lung,  secondary  cancer  of,  dif- 
fuse, 145 
Lungs,  examination  of,  8 
Lungs,    radiological    study    of, 
98 

Mediastinal  pleurisy,  45 

Mediastinal  pleurisy  with  effu- 
sion, 46 

Mediastinum,  displacement  of, 
22 

Method  of  procedure  for  ex- 
amination, 6 

Mobility  of  foreign  bodies  in 
bronchi,  82 

Morphological  significance,  90 

Movement  of  balance,  60 

Nature  of  foreign  bodies  in 
bronchi,  81 

Nature  of  projectile  in  penetrat- 
ing wounds,  etc.,  161 

Normal  images,  1 

Oblique  positions,  5 
CEdemas,  100 

(Edemas,  acute  active,  100 
(Edemas,  chronic  passive,  100 
(Edemas,    radioscopic    charac- 
teristics common  to,  100 


Paralysis  of  diaphragm,  theory 
of,  61 

Passive  congestion,  100 

Pleura,  cancer  of,  148 

Pleurae,  radiological  study  of, 
13 

Pleurisy,  after  effects  of,  29 

Pleurisy,  circumscribed  and  en- 
cysted, 34 

Pleurisy,  diagnosis  of  type  of, 
28 

Pleurisy,  diaphragmatic,  40 

Pleuris}',  drj%  31 

Pleurisy,  dry  diaphragmatic, 
44 

Pleurisy,  dry  mediastinal,  49 

Pleurisy  with  effusion,  15 

Pleurisy  of  hilus  region,  49 

Pleurisy,  interlobar,  34 

Pleurisy,  interlobar  with  effu- 
sion, 35 

Pleurisy  of  the  large  cavity,  15 

Pleurisy,  mediastinal,  45 

Pleurisy,  mediastinal  with  effu- 
sion, 46 

Pleurisy,  purulent  diaphrag- 
matic, 40 

Pleurisy,  radiological  prognosis 
of,  29 

Pleurisy,  serous  diaphragmatic, 
42 

Pneumonia,  102 

Pneumonia  in  adult,  103 

Pneumonia  in  children,  102 

Pneumonia  in  children,  progno- 
sis, 103 

Pneumonic  triangle,  102,  105 

Pneumothorax,  56 

Pneumothorax,  artificial,  72 

Pneumothorax,  double,  72 


INDEX 


181 


Pneumothorax,  limited  en- 
cysted, 70 

Pneumothorax,  radioscopic 

treatment  during  artificial 
75 

Pneumothorax,  spontaneous,  58 

Position  for  examination — an- 
terior, 1 

Position,  dorsal,  4 

Position,  frontal,  1 

Position,  oblique,  5 

Position,  posterior,  4 

Position  of  projectile  in  pene- 
trating wounds,  etc.,  162 

Position,  transverse,  4 

Primary  active  congestion,  99 

Procedure  in  examination,  6 

Processes,  vascular,  99 

Prognosis  of  pleurisy,  radio- 
logical, 29 

Prognosis  in  pneumonia  in  chil- 
dren, 103 

Projectile  in  penetrating 
wounds,  localization,  etc., 
163 

Projectile  in  penetrating 
wounds,  nature  of,  161 

Projectile  in  penetrating 
wounds,  search  for,  162 

Projectile,  position  of  in  pene- 
trating wounds,  etc.,  162 

Pseudo  effusions,  24 

Pseudo-lobar  broncho-pneu- 
monia, 106 

Pseudo-tuberculosis,  129 

Pulmonary  cavities,  135 

Pulmonary  emphysema,  1 13 

Pulmonary  gangrene,  111 

Pulmonary  lesions  associated 
with  effusion,  26 


Pulmonary  processes,  acute  in- 
fectious, 102 

Pulmonary  processes,  chronic, 
113 

Pulmonary  sclerosis,  114 

Pulmonary  tuberculosis,  117 

Pulmonary  tuberculosis,  exami- 
nation of  thoracic  cavity,  etc., 
125 

Pulmonary  tuberculosis,  radio- 
graphic examination  in,  122, 
123,  124 

Pulmonary  tuberculosis,  radio- 
scopic examination  in,  121, 
123,  124 

Pulmonary  tuberculosis  with 
clinical  signs  but  stethoscopic 
signs  negative,  etc.,  120 

Pulmonary  tuberculosis  with 
definite  clinical  and  stetho- 
scopic signs,  127 

Pulmonary  tuberculosis  without 
clinical  or  stethoscopic  signs, 
118 

Purulent  diaphragmatic  pleu- 
risy, 40 

Radiographic    examination    in 

,  pulmonary  tuberculosis,  122, 
123,  124 

Radiological  diagnosis  of  effu- 
sion, 24 

Radiological  prognosis  of  pleu- 
risy, 29 

Radiological  study  of  the 
bronchi,  79 

Radiological  study  of  the  lungs, 
98 

Radiological  study  of  the 
pleurae,  13 


182 


INDEX 


Radiological  study  of  penetrat- 
ing wounds  of  thorax,  161 

Radioscopic  appearance  of 
thorax  in  confirmed  tubercu- 
losis, 128 

Radioscopic  characteristics  com- 
mon to  oedema  and  conges- 
tion, etc.,  100 

Radioscopic  distinction  between 
groups  of  glands,  89 

Radioscopic  examination  of  the 
thorax,  1 

Radioscopic  examination  in  pul- 
monary tuberculosis,  121, 
123,  124 

Radioscopic  examination  and 
treatment  of  pulmonary'  tu- 
berculosis, 140 

Radioscopic  image  of  glands,  91 

Radioscopic  treatment  during 
artificial  pneumothorax,  75 

Respiration  in  pulmonary  tu- 
berculosis, study  of,  125 

Retrogression  of  effusion,  23 

Ribs,  examination  of,  8 

Sclerosis  of  the  interlobe,  39 
Sclerosis,  pulmonary,  114 
Serous  diaphragmatic  pleurisy, 

42 
Sinuses,  examination  of,  7 
Spontaneous  pneumothorax,  58 
Stenosis,  bronchial,  86 

Thoracic  aspiration,  theory  of, 
61 

Thoracic  cavity  in  pulmonary 
tuberculosis,  etc.,  125 

Thorax,  appearance  of  in  pleu- 
risy, 15 


Thorax,  dermoid  cysts  of,  148 

Thorax,  indications  and  contra- 
indications for  operation,  etc., 
171 

Thorax,  penetrating  wounds  of, 
155 

Thorax,  radioscopic  examina- 
tions of,  1 

Tolerance  of  bronchi  to  foreign 
bodies,  83 

Topographic  study  of  lesions  in 
tuberculosis,  132 

Tracheo-bronchial  adenopathy, 
89 

Transverse  position,  4 

Triangle,  pneumonic,  102,  105 

Tuberculosis,  appearance  of 
thorax  in  confirmed,  128 

Tuberculosis,  cured,  140 

Tuberculosis,  definite  cUnical 
and  stethoscopic  signs  in, 
etc.,  127 

Tuberculosis,  examination  of 
thoracic  cavity,  etc.,  125 

Tuberculosis,  pulmonary,  117 

Tuberculosis,  pulmonary,  with 
clinical  signs,  etc.,  120 

Tuberculosis,  pulmonary,  with- 
out clinical  signs,  etc.,  118 

Tuberculosis,  radiographic  ex- 
amination in  pulmonary,  122, 
123,  124 

Tuberculosis,  radioscopic  ex- 
amination in  pulmonary,  121, 
123,  124 

Tuberculosis,  radioscopic  ex- 
amination and  treatment  of, 
140 

Tuberculosis,  study  of  compli- 
cations in,  136 


INDEX 


183 


Tuberculosis,  study  of  develop- 
ment of  lesions  in,  134 

Tuberculosis,  topographic  study 
of  lesions  in,  132 

Tumors,  lung,  142 

Type  of  pleurisy,  diagnosis  of, 
28 

Vascular  processes,  99 
Visibility  of  foreign  bodies  in 

bronchi,  82 
Vomica,  false  recovery  through, 

37 


Wounds,  indications  and 
contra-indications  in  pene- 
trating, 171 

Wounds,  localization  of  pro- 
jectile in  penetrating,  163 

Wounds,  nature  of  projectile 
in  penetrating,  161 

Wounds,  position  of  projectile 
in  penetrating,  162 

Wounds,  search  for  projectile 
in  penetrating,  162 

Wounds  of  thorax  by  war  pro- 
jectiles, etc.,  155 


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